LIBRARY OF CONGRESS. 
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UNITED STATES OF AMERICA. 




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Is 

No. 13 IN THE PHYSICIANS' AND STUDENTS' READY- 
REFERENCE SERIES. 



A PRACTICAL MANUAL 



DISEASES OF THE SKIN 



GEORGE HTROHE, M.D., 

PROFESSOR OF MATERIA MEDICA, THERAPEUTICS, AND HYGIENE, AND FORMERLY PROFESSOR 

OF DERMATOLOGY IN THE COLLEGE OF PHYSICIANS AND SURGEONS, 

BALTIMORE, ETC., ETC. 



ASSISTED BY 



J. WILLIAMS LORD, A.B., M.D. 



LECTURER ON DERMATOLOGY AND BANDAGING IN THE COLLEGE OF PHYSICIANS AND 

SURGEONS ; ASSISTANT PHYSICIAN TO THE SKIN DEPARTMENT IN THE 

DISPENSARY OF JOHNS HOPKINS HOSPITAL. 




PHILADELPHIA AND LONDON ! 

THE F. A. DAVIS CO., PUBLISHERS, 
1892. 






-\\ 



<» 



Entered according to Act of Congress, in the year 1892, by 

THE F. A. DAVIS COMPANY, 

In the Office of the Librarian of Congress, at Washington, D. C, U. S. A. 



Philadelphia, Pa., U. S. A.: 

The Medical Bulletin Printing House, 

1231 Filbert Street. 



PREFACE. 



In this book no attempt is made to add one more 
to the already numerous works for the dermatological 
specialist. Hence, little space is given to theoretical 
speculations upon pathology and etiology. It is hoped, 
however, that the medical student and practitioner will 
find, in the following pages, some return in practical 
value for the time spent in their perusal. 

The author takes occasion to express his obligations 
for assistance to Dr. J. Williams Lord, his former chief, 
of clinic and present successor in the Chair of Derma- 
tology in the College of Physicians and Surgeons. 

Baltimore, Md., December 15, 1891. 



(iii) 



TABLE OF CONTENTS. 



PAGE 

Introduction . 1 

Anatomy and Physiology of the Perspiratory 

Glands 3 

Disorders of the Sweat Glands 5 

Quantitative derangements of the secretion of sweat . 5 

Hyperidrosis 5 

Anidrosis 8 

Qualitative disorders of the sweat secretion 9 

Bromidrosis 9 

Chrornidrosis . . . 9 

Uridrosis 10 

Sudamen 10 

Prickly heat 10 

Anatomy and Physiology of the Sebaceous Glands 15 

Diseases of the Sebaceous Glands 16 

Functional disorders of the sebaceous glands 16 

Seborrhoea 16 

Comedo 19 

Milium 21 

Steatoma . . . *. '" 21 

Asteatosis " 22 

Structural diseases of the sebaceous glands and peri- 
follicular tissues 22 

Acne 22 

Acne rosacea „ 28 

Sycosis 30 

Eczema . . . . 37 

General considerations . „ 37 

Acute eczema 40 

Chronic eczema 44 

Inflammations of the Skin 66 

Erythema 66 

Urticaria 70 

00 



vi Table of Contents. 

PAGE 

Simple inflammations of the skin 77 

Erysipelas 84 

Furuncle 86 

Anthrax 88 

Diffuse phlegmon 89 

Malignant pustule 90 

Herpes simplex 91 

Herpes zoster ..'..' 92 

Dermatitis herpetiformis 96 

Psoriasis 98 

Exfoliative dermatitis 104 

Acute exfoliative dermatitis of infants. . . . 104 

Bullous exfoliative dermatitis 107 

Chronic general exfoliative dermatitis .... 107 

Local exfoliative dermatitis 108 

Lichen. . . 109 

Prurigo Ill 

Atonic pustular eruptions . Ill 

Contagious impetigo 113 

Pemphigus 114 

HEMORRHAGES 119 

Symptomatic cutaneous hemorrhages 119 

Purpura 119 

Scurvy 121 

Hypertrophies of the Skin 123 

Pigmentary hypertrophies . 123 

Freckles ..'.'..' 123 

Chloasma 124 

Hypertrophies of the epidermal and papillary layers . 127 

Epidermal hypertrophy of old age .... . . 127 

Epidermal accumulation at the mouths of the hair- 
follicles . . ^ .129 

Epithelial molluscum . 130 

Callosities 131 

Corns 131 

Warts 134 

Cutaneous horns 137 

Pigmentary nsevus 138 

Ichthyosis 141 

Hypertrichosis 144 



Table of Contents. vii 

PAGE 

Hypertrophies of the connective-tissue layers .... 152 

Scleroderma 152 

Sclerema neonatorum 154 

Elephantiasis arabuin 155 

Atrophies > 159 

Atrophia cutis . . . ' 159 

Atrophy of pigment 161 

of hair 163 

New Formations of the Skin 168 

Epithelial new formations 168 

Epithelioma 168 

Connective-tissue new formations 173 

Keloid 173 

Fibroma 174 

Xanthoma 176 

Rhinoscleroma . . 176 

Sarcoma . 177 

Lepra 178 

Scrofuloderma 182 

Lupus erythematosus 183 

Lupus vulgaris 185 

Ainhum 189 

Podelcoma 189 

Myoma . . . ■ . c 190 

Neuroma 191 

Perforating ulcer of the foot 191 

Vascular new formations 192 

Lymphangioma 192 

Angioma . 192 

Telangiectasis .* 194 

Neuroses 196 

Hyperesthesia 196 

Anaesthesia . . 196 

Dermatalgia 196 

Pruritus 197 

Parasitic Skin Diseases 199 

Vegetable parasitic skin diseases . . ; 199 

Tinea favosa 200 

Tinea trichophytina 201 

Tinea versicolor 203 



viii Table of Contents. 

PAGE 

Animal parasitic skin diseases . 205 

Scabies 205 

Pediculosis 206 

Cutaneous Manifestations of Syphilis ...... 209 

General considerations 209 

General morphology and classification 210 

General diagnostic features , 211 

Chronological sequence and course of eruptions • 211 

Localization and distribution 213 

Color 214 

Multiformity of lesions 216 

Configuration of eruption 216 

Subjective symptoms 217 

Racial peculiarities 217 

Recapitulation , . 218 

The erythematous syphilide 220 

The papular syphilide 228 

The pustular syphilide 240 

Tertiary syphilitic eruptions 246 

The tubercular syphilide 248 

The nodular syphilide , 252 

The ulcerating syphilide 257 

The pigmentary s} r philide 262 

Syphilitic alopecia 266 

diseases of the nails 268 

Treatment of the syphilides 268 

General treatment 269 

Local treatment 284 

Formula 290 



PRACTICAL MANUAL 

OF 

DISEASES OF THE SKIN. 



INTRODUCTION. 



A knowledge of the diseases of the skin is of great 
importance to the practitioner. Although skin dis- 
eases do not, as a rale, tend to shorten life, the discom- 
fort or disfigurement they produce are so annoying 
that persons afflicted with them are more emphatic in 
their demands for relief than if suffering from maladies 
of much greater gravity. An eczema of very limited 
extent, a simple ringworm, or an ordinary eruption of 
acne, will frequently cause the patient more anxiety 
than a catarrhal pneumonia with its dangerous sequel, 
or a reducible hernia with its constant menace of fatal 
strangulation. 

The student or young practitioner will find it to his 
advantage to give some time and attention to the study 
of this branch of practical medicine. In every com- 
munity there are sufferers from curable skin diseases 
who are compelled to bear their afflictions }^ear in and 
year out because the physicians to whom they have 
applied for relief failed to recognize the character of 
the disease, or, recognizing it, failed to apply the appro- 
priate remedy. Hence, a practical knowledge of the 
diagnosis and treatment of skin diseases may not seldom 

(i) 



2 Introduction. 

have a decisive influence upon the 3 r oung practitioner's 
success in obtaining a practice. 

It must be confessed, however, that the impression 
made by most text-books of dermatology is not reas- 
suring. Complicated classifications or u systems," an 
awkward nomenclature, great prolixity and a lack of 
definiteness in the description of typical diseases, and 
an undue multiplication of morbid processes are the 
besetting sins of many of our standard works. 

In the following pages I have tried to give brief and 
exact descriptions of the various diseases considered, 
and to indicate the simplest and most direct methods of 
treatment. The needs of the practitioner have been 
primarily kept in view. Theoretical questions have 
been entirely subordinated to plain matters of fact. 



ANATOMY AND PHYSIOLOGY OF THE 
PERSPIRATORY GLANDS. 



The perspiratory glands consist of simple tubules, 
which at their blind extremities are coiled up into a 
spherical mass imbedded in the lower portion of the 
derma, or in the subcutaneous tissue, where they are 
generally in relation with a mass of fat. The duct, or, 
rather, that part of the gland not coiled up, passes 
through the cutis in a straight or slightly wavy line, 
but becomes spirally twisted on its way through the 
epidermal layer, ending in a funnel-shaped opening on 
the surface. 

The sweat glands are most numerous in the palms, 
soles, and axillae. They are entirely wanting in the 
glans penis, prepuce, and the margin of the lips. The 
average number to the square inch is one thousand, and 
the total number is estimated at nearly two and a half 
millions, with a secreting surface of about forty thousand 
square inches. The total length of tubing, supposing 
the convoluted ends to be uncoiled, would amount to 
nearly eighty miles. 

In the axilla the diameter of the sweat glands is 
from one-third of a line to a line and a half. (Krause.) 

The main function of the perspiratory glands is the 
secretion of sweat. The smaller glands are lined with 
a nucleated pavement epithelium, while the larger ones 
have a lining of cylindrical epithelial cells. The convo- 
luted portion of the gland is surrounded by a net-work 
of capillaries. They are also richly supplied with nerves. 
Their secretion contains water, fats, and volatile fatty 
acids, cholesterin, urea, chlorides, and phosphates. Its 

(3) 



4 Diseases of the Skin. 

normal reaction is alkaline. Under certain conditions 
of defective action of the kidneys, the skin may perform 
the function of these organs vicariously. 

The suppression of cutaneous perspiration was for- 
merly looked upon as very serious and generally fol- 
lowed by fatal results. Experiments made upon small 
animals (rabbits), by covering the entire surface with an 
impervious varnish, resulted in the death of the animals. 
These experiments are not conclusive, however, for it 
has been found that large dogs and horses thus treated 
do not die. The fatal result in the smaller animals is 
explained by the rapid loss of heat from the surface 
when this is covered with an impervious material. 

The secretion of sweat varies in different individuals. 
It is also influenced by differing conditions of environ- 
ment, such as heat and cold, muscular exertion, dilata- 
tion of the superficial vessels, increased blood-pressure, 
abundant or hot drinks, certain medicines, and, above 
all, the action of certain nerves. 

Stimulation of the vaso-dilator or paralysis of the 
vaso-constrictor nerves may produce increased secretion 
of sweat. Excitation of certain special " sweat nerves," 
the centres of which are situated in the medulla (Naw- 
rocki, Ott) and spinal cord (Luchsinger), causes active 
secretion. It has been found that this secretion may 
be produced on stimulating the sweat nerves, even after 
the extremity has been severed from the body. 

" Sweating may be brought about as a reflex act. 
Thus, when the central stump of the divided sciatic (in 
which are contained the sweat fibres) is stimulated, 
sweating is induced in the other limbs, and the intro- 
duction of pungent substances into the mouth will fre- 
quent^ give rise to a copious perspiration over the side 
of the face." 1 

1 Foster : Physiology. Second Am. ed., p. 499. 



DISORDERS OF THE SWEAT GLANDS. 



The disorders of the sweat glands are functional; 
no structural alteration of these glands, independent of 
any other disease, is known. The sweat may vary in 
quantity or he altered in quality. The quantitative 
variations in secretion consist in excessive secretion 
(hyperidrosis) and deficient secretion panidrosis). 

I. Quantitative Derangements of the Secretion op 

Sweat. 

hyperidrosis — excessive sweating. 

The quantity of sweat excreted in health varies so 
widely in different individuals that it is difficult to indi- 
cate the dividing line between physiological and patho- 
logical sweating. 

Hyperidrosis may be general or local. The former is 
most likelj 7 to be an accompaniment of some diseased 
state, as phthisis ; or it imvv occur in the course of an 
acute febrile affection, as pneumonia, typhoid, malarial, 
or relapsing fevers. In the latter class of diseases the 
sweating is an indication of defervescence, and requires 
no treatment. The phthisical sweats frequently demand 
therapeutic interference on account of their exhausting 
effects. 

Among the general hj'peridroses may be mentioned 
the so-called " sweating sickness " which formerly pre- 
vailed epidemically in portions of Europe, and which has 
been observed in France as late as the year 1887. For 
details in regard to this curious disease the reader is 
referred to the author's " Text-Book of Hygiene." 

(5) 



6 Diseases of the Skin. 

General hj-peridrosis is often an accompaniment of 
corpulence, constituting a very annoying complication 
of this derangement of nutrition. 

Local hyperidrosis in the majority of cases affects 
the palms of the hands, soles of the feet, or the axillae. 
The foot and axillary sweat has often a very offensive 
odor. 

This odor is not present in the freshly-secreted sweat, 
but is developed in consequence of certain chemical 
changes in the secretion. Thin belieA^es it to he due to 
the presence of an organism which he has named bacte- 
rium fcetidam. Persons so affected are constantly 
environed by a fetid exhalation, and ma} T be literally said 
to " stand in bad odor." 

Local sweating also accompanies many nerve lesions 
or disturbances. Thus, migraine is often accompanied 
by excessive perspiration limited to the area of distri- 
bution of the affected nerve. 

The general treatment of the excessive sweats of 
phthisis consists in tonics and astringents. Aromatic 
sulphuric acid in fifteen drop doses four to six times 
daily is often of great utility. Atropine in doses of 
vho ^° ilo g** 1 * 11 (one-third to half a milligramme) can 
be relied upon with much confidence to check the exces- 
sive secretion, although a permanent effect cannot be 
hoped for. In these cases local treatment is usually of 
little avail. 

The treatment of the hyperidrosis of obesity is of 
no avail without such measures as will at the same time 
result in a diminution of the accumulated fat. 1 

In the local hyperidroses the principal reliance must 
be placed upon local measures. Of course, the condition 

1 See "The Guiding Principles in the Treatment of Excessive Corpu- 
lence," in Phil. Med. Times, vol. xvii, pp. 799, 826. 



Disorders of the Sweat Glands. 7 

of the general health demands attention, and anaemia or 
digestive derangements require appropriate treatment. 
Aside from this the constitutional treatment can be 
summed up under the general head of hygienic measures, 
— good food, fresh air, exercise, and possibly tonic 
medicines. 

For the disagreeable sweating of the palms, a lotion 
of tannic acid, 2 to 3 grains to the ounce of alcohol 
(1 to 200), or simply cologne-water or bay -rum (For- 
mula 1), are very useful. The application of one of 
these may be followed by a dusting-powder of starch, 
prepared chalk, or orris-root. Either of these may be 
combined with oxide of zinc, boracic acid, salicylic acid, 
or calamine, with good effect (Formulae 2 to 4.) Similar 
measures will generally be effectual in excessive sweat- 
ing of the axillary region. 

For the excessive malodorous sweating of the feet 
(bromidrosis), many remedies have been recommended. 
In the milder cases, baths of alum-water, followed by 
one of the above-mentioned dusting-powders, are some- 
times effectual. Formula 5 is used with success by the 
German army-surgeons. For the severer grades of the 
affection, however, in which the feet are constantly 
bathed in sweat, the epidermis macerated, and the skin 
reddened and tender, and at the same time diffusing a 
most penetrating and offensive odor, there is only one 
method of treatment known to me which can be relied 
upon. It was introduced by Hebra, and has, in numerous 
cases under my care, never failed to cure the disease. 
The procedure is as follows : — 

The feet are first washed and thoroughly dried. 
Each foot is then enveloped in a piece of linen or muslin 
of proper size (about one foot square) thickly spread 
with diachylon ointment (Hebra 's ointment, ung. vaselini 



8 Diseases of the Skin. 

plumbicum ; see Formulae 5, 6). Small pieces of linen 
spread with the ointment are also inserted between the 
toes. Clean foot-wear is then put on. On the following 
daj 7 the cloths are taken off, the feet wiped dry with a 
towel, but not washed. One of tile absorbent powders 
above mentioned (Formula 4) is thickly dusted on, and 
the feet again enveloped with the ointment. This pro- 
cedure is repeated daifv from ten daj^s to two weeks, 
during which time the feet must not be washed. The 
ointment is then omitted, but the powder is still used 
several times a da} 7 . After a few days the epidermis is 
exfoliated in thick, 3 T ellowish, parchment-like flakes, and 
new, soft skin appears. Now for the first time the feet 
may be washed. The new epidermis is of a healthy, pink 
color, and the secretion normal. The powder should be 
continued for some time. 

If the hyperidrosis is not entirely cured, the same 
course should be repeated ; but this is rarely necessaiy. 

Thin recommends dusting the shoes and stockings 
with boracic acid, and wearing a cork sole on the inside 
of the shoe. He also advises the application of a boracic 
acid ointment (Formula 7). 

ANIDROSIS — DEFECTIVE EXCRETION OF SWEAT. 

This should properly be termed hypohidrosis, as the 
secretion is rarely entirely suppressed. It accompanies 
certain grave constitutional or nervous affections, as 
diabetes, tuberculosis, n^elitis, and poliomyelitis. 
Locally it also occurs on eczematous, psoriatic and 
ichthyotic patches. 

The treatment in each case will be that appropriate 
-to the underlying general or local condition. The dry- 
ness of the skin may be relieved by the glycerite of 
starch (Formula 8). 



Disorders of the Sweat Glands. 9 

II. Qualitative Disorders of the Sweat Secretion. 

BROMIDROSIS — ODOROUS SWEAT. 

Certain nervous diseases are accompanied by modi- 
fications of the odor, with or without increase in the 
quantity of the perspiration. Hammond has reported 
several cases of this kind. The odor is not always 
offensive, but may even be agreeable, as in Hammond's 
cases, in two of whom it resembled that of violets. 

In the majority of cases, however, the odor of the 
sweat in bromidrosis is the reverse of agreeable, and is 
nearly always due to decomposition of the secretion. 
The treatment of these cases is that mentioned on page 
7. In one of Hammond's cases salicylate of sodium 
in 5-grain (.3 gramme) doses arrested the hj T peridrosis 
as well as the emission of the odor. 

CHROMIDROSIS — COLORED SWEAT. 

The perspiratory secretion is usually colorless, but 
sometimes it presents a distinct color. Red, blue, 
green, yellow, and black sweats have been reported. In 
many of the reported cases the color was, doubtless, due 
to some reaction between the sweat and some material 
adhering to the skin or in the clothing. In others the 
discoloration was intentionally produced. Colored 
sweat is also sometimes found in company with uterine 
or ovarian disorder. In this category probablj 7 belong 
the cases of bloody sweat, or ephidrosis cruenta, so far 
as the reports may be considered as trustworthy. So 
competent an observer as Dr. McCali Anderson has 
reported an interesting case of this affection, and has 
quoted a number of others from Erasmus Wilson, T. 
K. Chambers, Pinel, and other authors. It is noticeable 
that, in all but one of the cases mentioned, the points 
of appearance of the bloody fluid were on the front of 

l* 



10 Diseases of the Skin. 

the body, or on such portions of the surface as could be 
readily reached with the hands. 

Duhring states that colored sweat is " not infre- 
quently connected with uterine disorders," and gives 
references to a large number of reported cases. In red 
and yellow sweat E berth and Babes iu have found bac- 
teria. It is not improbable that colored sweat, unless 
feigned, is always due to the presence of minute organ- 
isms. It is known, for example, that the color of blue 
pus is produced by a bacterium. 

The treatment might be rationally germicidal. A 
lotion of mercuric bichloride one grain to the ounce 
(1 to 500) or Labarraque's solution (liq. sodse chlorinatse) 
should be effective in case the color is due to micro- 
organisms. 

URIDROSIS — URINOUS SWEAT. 

In cases of kidney disease, in Asiatic cholera, and 
in experimental observations on the cutaneous perspira- 
tion, urea and other constituents of the urine have been 
found in the sweat. As this is merely an incident in 
some grave underlying disease generally, it does not 
require any special treatment. 

SUDAMEN — SWEAT BLISTERS. 

In cases of typhoid, typhus, and puerperal fevers, 
rheumatism and pneumonia, there is frequently an 
eruption of minute whitish, or pearly, non-inflammatory 
vesicles, coincident with the so-called "critical sweat." 
The vesicles are due to the excessive secretion, which 
elevates the epidermis in minute areas. The eruption 
has no especial significance, and requires no treatment. 

PRICKLY HEAT. 

Under ordinary circumstances the average quantity 
of sweat secreted in twenty-four hours by a healthy 



Disorders of the Sweat Glands. 11 

adult is about twelve ounces. This, however, is ma- 
terially modified by varying conditions of external tem- 
perature, character, and amount of food and drink, 
dress, emotional conditions, or the swallowing of certain 
medicines. The exact quantity of fluid and other 
matters discharged daily in the sweat can, therefore, not 
be definitely stated. 

Ordinarily this secretion takes place without pro- 
ducing anj r discomfort; but when it becomes excessive 
in consequence of the causes mentioned, it often gives 
rise to a most aggravating and troublesome disease of 
the skin. 

The characteristic features of prickly heat are so 
familiar as to make any extended description unneces- 
sary. It occurs in the form of small, bright-red pim- 
ples, rarely larger than a pin-head in size, thickly 
scattered over the surface of the body, and accompanied 
by a most distressing sense of tingling, burning, and 
itching. Often the small red pimples are capped by a 
minute blister containing a droplet of a colorless or 
pearly fluid. The eruption m&y appear anywhere upon 
the skin except the palms of the hands and soles of the 
feet, where it is rarely or never seen. It is nearly 
alwaj T s limited to those portions of the body covered 
by the clothing. In plump, well-fed children, it is also 
often seen in the folds of the skin at the front of the 
neck. 

These little red elevations indicate the mouths of 
the sweat glands, which are irritated and inflamed in 
consequence of excessive activity. This is generally 
due to high temperature, excessive exertion, and unsuit- 
able clothing. The inordinate use of hot drinks, con- 
finement in close, ill-ventilated apartments, lack of 
attention to proper cleanliness of the skin, improper 



12 Diseases of the Skin. 

administration of medicines containing opiates or simi- 
lar drugs which have an irritating action upon the 
skin, may give rise to or intensify this disease. Dis- 
turbances of digestion are also believed to be effective 
in its causation. 

The distress caused b} r the eruption leads the sufferer 
to seek relief by rubbing and scratching the affected 
surface. The ease obtained in this wa}^ is only tem- 
porary, however, and in a short time the itching and 
burning return with greater intensity, the scratching is 
repeated, and, if no relief is given bj T medical means or 
a cessation of the cause, an inflammation of the skin 
proper — an eczema — may be produced, which will 
often persist a long time and prove very resistant to 
treatment. 

I may be permitted to digress here for a moment to 
call attention to the frequency with which this very 
obstinate and troublesome disease is the result of neglect 
of very trivial ailments. An outbreak of prickly heat, 
or nettle-rash, or a simple chafe, if neglected or im- 
properly treated, is often followed by an eczema lasting 
months or years — nay, which not infrequently attends 
the individual throughout life. Dermatologists see 
cases almost dail}' in which the ounce of prevention, 
properly applied, would have far outweighed many 
pounds of cure. 

The use of flannel next to the skin, especially during 
hot weather, is the principal avoidable cause of prickly 
heat. Flannel clothing ought at no time to be worn 
directly in contact with the skin. 

Prickly heat is often greatly intensified hy improper 
methods of treatment. Hot drinks or other sudorific 
remedies internally and irritant local applications 
nearly always make the disease much worse. 



Disorders of the Sweat Glands. 13 

An eruption very similar in appearance to prickly 
heat sometimes affects children when teething, or when 
suffering from an attack of acute indigestion or similar 
complaint. This is a fine nettle-rash. It is not limited 
to the parts covered by clothing, and not rarely attacks 
the palms of the hands and soles of the feet. The itch- 
ing is usually more intense than in prickly heat. The 
eruption appears and passes away suddenly, and may 
often be made to disappear by an emetic or brisk purge. 

It is a popular fallacy that the eruption of prickly 
heat is salutary, and that no effort should be made to 
cure it for fear of'" driving it in " and causing some 
other serious disease. There is no need to fear any 
ill consequences from a rapid cure of the complaint. 
The danger is, rather, as already pointed out, that if 
neglected it will develop into another and much more 
obstinate disease. 

Prickty heat need rarely cause much difficulty in 
treatment. The following measures will usually succeed 
in promptly relieving the intense irritation and restor- 
ing the normal condition of the skin : — 

The dress should be light, all flannels and impervious 
articles of clothing being removed. Cool baths should 
be taken often enough to remove the perspiratory secre- 
tion before it decomposes, and to keep the skin cool. 
After the bath, the skin should be carefully dried with 
a soft towel, and the affected surfaces powdered with 
starch-powder, or a mixture of starch and oxide of zinc 
(Formula 2), or carbonate of zinc and orris-root (For- 
mula 3). 

Lotions containing alcohol, as cologne-water or bay- 
rum, may also be used when the outbreak is local, 
following the lotion with one of the powders. Formula 
No. 4 will often be of good service. All powders used 



14 Diseases of the Skin. 

should be perfectly smooth and contain no gritty par- 
ticles. Preparations containing sulphur should be 
avoided, as they are more likely to increase than to 
alia}' the irritation. 

If the itching is excessive, lotions containing one to 
two drachms of bicarbonate of soda to the pint of water 
(1 to 100) may be applied with a soft sponge and 
allowed to dry on the skin. Ointments must not be 
used, as they nearly always aggravate the complaint. 

If the eruption covers the entire surface, alkaline 
baths, containing two to four ounces of carbonate of 
soda to the bath, or bran baths, may be employed, and 
will rarely fail to give at least temporary relief from the 
excessive itching. A bran bath is prepared b}Mnclosing 
from five to six pounds of bran in a thin muslin bag and 
steeping it in the bath for fifteen to twenty minutes 
before using the bath. The bag should be occasionally 
kneaded and squeezed, in order to diffuse the mucilag- 
inous contents throughout the water. Gelatin and 
starch baths, containing one to two pounds of gelatin 
or one pound of starch to the bath, are also often valu- 
able aids in the treatment. After each bath the skin 
should be carefully dried without friction and dusted 
with starch, as above directed. 

The causes of the disease should be avoided, if 
possible. 



ANATOMY AND PHYSIOLOGY OF THE 
SEBACEOUS GLANDS. 



The sebaceous glands are tabulated glandular organs 
found in all parts of the skin except the palms of the 
hands, soles of the feet, and the dorsal surfaces of the 
third digital phalanges. Special varieties of these 
structures are Tyson's glands on the glans penis, the 
Meibomian glands, and the ceruminous glands of the 
external meatus. They are nearly always in connection 
with a hair-follicle. If the hair is thick, as in the scalp 
or beard, the glands seem to be appendages to the hair- 
follicle, and discharge their secretion into the follicular 
canal. On the other hand, the fine hairs seem to be 
merely appendages to the gland, the duct of the latter 
opening directly upon the surface, and the hair-shaft 
passing out through the gland-duct. The glands in the 
tegument of the glans penis are not connected with hair- 
follicles. 

The number of sebaceous glands in the skin of the 
adult is estimated by Build ey as at least six hundred 
thousand. Their size varies extremely, measurements 
having been given at ^q to ^ inch in diameter. 

The secretion of the sebaceous glands consists of 
epithelial debris, cholesterin, fat, and fat-ciystals. Its 
function is probably to keep the skin and hair soft and 
pliable, and to limit absorption and evaporation. 



(15) 



DISEASES OF THE SEBACEOUS 
GLANDS. 



The diseases of the sebaceous glands may be divided 
into functional disorders and structural lesions. The 
latter frequently arise from the former. 

I. Functional Disorders of the Sebaceous Glands. 

SEBORRHEA EXCESS AND ALTERATION OF THE SEBACEOUS 

SECRETION. 

Seborrhoea appears under two forms, — Seborrhoea 
sicca and Seborrhoea oleosa. The former is generally 
found upon the hairy scalp and the trunk, while the 
latter is often localized upon the face. 

Dry seborrhoea of the scalp is frequent in infants, in 
whom the head is covered with a more or less thick 
yellowish or brownish crust, under which the skin is 
dry and of the normal color, or slightly hyperaemie. 

In the adult, seborrhoea of the scalp usually appears 
in the form of a furfuraceous desquamation, popularly 
known as " dandruff." In some cases, however, the 
scales are massed together in a firm Layer, under which 
the skin is frequently reddened. When seborrhoea of 
the scalp lasts for some time it usually causes loss of the 
hair. It is probable that by far the majority of cases 
of early baldness are due to neglected or improperly 
treated seborrhoea ; hence the importance of early atten- 
tion to this apparently insignificant affection. 

Upon the chest and back, seborrhoea generally ap- 
pears in the form of roundish or irregular red patches, 
(16) 



Diseases of the Sebaceous Glands. 17 

covered by a layer of loose, whitish, greasy scales. 
Such patches are often found upon the sternal region, 
and may easily be mistaken for psoriasis. 

Seborrhea oleosa is almost exclusively limited to 
the face, especially the nose and cheeks. The skin of 
these parts is smooth, oil}', and shining. Dust rapidly 
accumulates on the oily surface, and the affected indi- 
viduals find it almost impossible to keep clean. 

The causes of seborrhcea are not well known ; but it 
is often an accompaniment or a consequence of contin- 
ued fevers, syphilis, tuberculosis, or general anaemia. 
In many cases no reason for its existence can be dis- 
covered. 

The diagnosis of seborrhcea rarely presents any 
difficulty. At times, however, it bears such a close 
resemblance to some other common diseases as to ren- 
der a careful examination necessary in order to come to 
a positive decision. 

The diseases with which seborrhcea is likely to be 
confounded are eczema, psoriasis, and ringworm. 

In eczema there is always more redness of the skin 
and greater itching than in seborrhcea. There is also 
general^, at some stage of eczema, serous discharge, 
which is never present in seborrhcea. 

In psoriasis, the scales are dry, silvery white, and 
seated upon a bright or deep-red, slightly-elevated base, 
with a sharplj'-defined margin. In seborrhcea the scales 
are usually dirt3 T -white, gi'ayi&h^ or yellowish, and greasy 
to the touch. The border between the affected and 
normal skin is not well defined. 

The small patches of seborrhcea upon the chest some- 
times resemble ringworm. Here the microscope will 
generally decide the nature of the affection by reveal- 
ing the spores or mycelium of the fungus of ringworm. 

A 9 



18 Diseases of the Skin. 

The treatment is principally local. If scales have 
accumulated to form crusts, these must be softened by 
some oily application. Sweet-oil and almond-oil are 
excellent for this purpose. Vaseline and cosmoline are 
unsuitable, as they *do not saponify in the presence of 
alkalies (soaps), and hence are difficult to remove, espe- 
cially from the hairy scalp. Fresh dehydrated lard 
answers much better. 

The application of a hot, moist poultice for several 
hours often promotes the loosening of the scales. After 
thorough softening of the crust, the scalp or the part 
affected is washed with soap and w r ater. The best sonp 
for this purpose is the German soft soap (sapo viridis). 
This soap has a strong odor of fish-oil, which makes it 
very disagreeable. The odor can be very well covered, 
however, by dissolving the soap in alcohol and adding 
a little oil of lavender or bergamot. This constitutes 
Hebra's spiritus saponis kalinus. (Formula 9.) About 
a tablespoon ful of this is poured upon the scalp, and, 
with the addition of water, smart friction produces a 
copious lather. The soap is washed out with clean 
water, and leaves the scalp clean, but usually with a 
tense sensation, as if the skin was stretched too tightly 
over the skull. A little oily application, such as vase- 
line, cold-cream, or almond-oil, will relieve this uncom- 
fortable feeling. In mild cases the shampooing and 
inunction of the scalp with a simple unguent will after 
a time cure the disease ; but in chronic cases something 
more will be required. Here some of the mercurial 
preparations, as Formulae 10, 11, 12, or one containing 
sulphur, as Formulae 13, 14, or tar (Formula 15), will be 
necessary. I have found carbolic-acid ointment, gr. xv 
to §j vaseline (1 to 30), to yield most excellent results. 

The general treatment also demands attention. In 



Diseases of the Sebaceous Glands. 19 

anaemic or chlorotic individuals, iron in the form of 
pills of the proto-carbonate (Bland's ferruginous pills, 
Formula 16), or In combination with arsenic, as recom- 
mended by the late Sir Erasmus Wilson (Formula 17), 
is indicated. The tincture of the chloride, especially if 
made palatable (Formula 18), is also a most active 
chalybeate. 

Chronic derangement of the function of digestion 
is also often present in cases of seborrhoea, and requires 
appropriate treatment. In acid dyspepsia, I have often 
obtained excellent results from the administration of 
lime-water and calumba (Formula 19). 

Many patients suffering with disorders of the seba- 
ceous glands are subject to habitual constipation. In 
these cases, the best drug I have used is cascara sagrada. 
I generally prescribe the cascara cordial prepared by 
Parke, Davis & Co., and have always obtained excellent 
results from its use. Its agreeable taste renders it a 
very desirable medicine. It is not objected to by the 
most fastidious patients. The fluid extract not rarely 
gripes and nauseates. I have never known the cordial 
to produce these effects. It should be given in tea- 
spoonful-doses once or twice a day, until one daily 
evacuation is regularly produced. In dispensary 
practice I have used with satisfaction for a number of 
years a combination of sulphate of magnesia and iron 
(Formula 20). 

COMEDO. 

Comedones are small, solid elevations of the skin 
caused by the retention of the sebum in the gland- 
ducts. They can be squeezed out of their seat by 
lateral pressure, and appear as short yellowish or 
whitish fatt}^ pings, with the outer extremity of a 
blackish color, known in the vernacular as " black- 



20 Diseases of the Skin. 

heads," or u flesh-worms." They are found in greatest 
numbers upon the face, chest, and back. They are 
unaccompanied by inflammation. 

Xeglect of cleanliness is the most frequent cause of 
comedones. They nre most frequent in young persons 
between the ages of twelve and twenty-live. At times 
no cause can be discovered. The diagnosis can never 
present any difficulty. 

The treatment of comedo is simple. The sebum 
plugs must first be expressed from the gland-ducts. 
This can readily be accomplished by means of a comedo 
extractor, or a watch-key. The opening of the key is 
placed directly over the black extremity of the plug 
and direct downward pressure made, when the plug is 
usually easily extruded. Then the skin is washed with 
soap and water, spirit as saponis kalinus (Formula 9) 
being an excellent form in which to use the soap. 
Afterward, a mild, stimulating application should be 
made to the skin in order to produce contraction of the 
calibre of the gland-duct and prevent re-accumulation 
of the secretion in it. For this purpose a mild sulphur 
or mercurial ointment (Formulae 11, 13) is useful. Van 
Harlingen recommends a combination of kaolin, glycerin, 
and vinegar (Formula 21), which I have used with some 
success. 

Should the frictions with soap produce irritation 
and desquamation of the skin, the}' may be inter- 
mitted for a few da} T s, and a soothing ointment, such as 
oxide-of-zinc ointment, or cold-cream with starch (For- 
mula 22), applied in the interval. When the irritation 
has subsided, the soap-friction must be resumed. 

If the patient is anaemic or debilitated, the adminis- 
tration of iron, in the form of acid tincture of the 
chloride (Formula 18), is indicated. 



Diseases of the Sebaceous Glands. 21 

MILIUM — SMALL RETENTION-CYST OF SEBACEOUS FOLLICLE. 

This occurs in the form of small, white or pearly, 
elevated papules, principally situated about the e}'elids. 
They are very superficial, being merely covered by epi- 
dermis. They are not likely to be mistaken for any 
other disease. 

The best treatment is electrolysis. An electrolytic 
needle inserted into the growth or passed through its 
base, and the circuit closed with ^ to 1 milliampere 
current for a minute, will usually be effectual. After 
a few days the papule falls off, leaving no scar. The 
slightly pigmented mark which remains gradually fades 
out. Simple puncture and expression are also often 
effectual. 

STEATOMA — SEBACEOUS CYST ; WEN. 

Wens are retention-cysts of the sebaceous glands 
which frequently grow to considerable size. They may 
occur on any portion of the body where there are seba- 
ceous glands, but are most frequently found on the 
scalp, face, neck, and back. 

The diagnosis between steatoma and lipoma is 
sometimes difficult. Puncture with an exploring- 
needle or bistoury and compression will, however, 
disclose the contents of a steatoma and clear up the 
diagnosis. 

The treatment consists in extirpation of the entire 
gland. Incision and expression of the contents of the 
sac may succeed, if the interior is thoroughly cauter- 
ized with lunar caustic. Small cysts may also be 
destroyed by electroh T sis. 

Anaesthesia may be produced by injecting a few 
drops of a 4-percent, solution of 113'drochlorate of 
cocaine alons; the line of incision. 



22 Diseases of the Skin. 

ASTEATOSTS — DIMINISHED SECRETION OF SEBUM 

This occurs only in conjunction with other patho- 
logical conditions ; most markedly with xeroderma. 
Persons whose hands come in frequent contact with 
alkalies, alcohol, ether, etc., often suffer from an arti- 
ficial asteatosis, i.e., the sebaceous matter is properly 
secreted, but is immediately dissolved in the chemical. 

The treatment consists in supplying fat to the skin, 
by means of frictions with lanolin, cold-cream, almond- 
oil, etc. 

II. Structural Diseases of the Sebaceous Glands 
and Perifollicular Tissues. 

acne. 

During the period of puberty many of the organs of 
the body take on a new development. The sebaceous 
glands of the skin participate in this growth, and, as a 
consequence, a greater or less degree of functional dis- 
turbance of these organs is likely to result. The most 
common form of this functional disturbance consists in 
an alteration in character and quantity of the sebaceous 
secretion. The sebum secreted is thicker and is not so 
readily extruded from the gland-ducts. These latter 
become filled with little plugs of the secretion, which 
distend the ducts, and thus produce small papules, with 
sometimes a slight depression of the summit, which is 
colored black or brown. This little spot of color is the 
mouth of the duct filled with the secretion, and the dis- 
coloration depends upon the deposit of dirt, — dust, 
carbon, etc., which has adhered to the end of the greasy 
plug, as has already been described. 1 

This is the first stage, in the vast majority of in- 

1 See ante, p. 19. 



Diseases of the Sebaceous Glands. 23 

stances, of the disease known as acne. The French 
writers term it acne sebacee ; while in the English and 
German literatures it is known as comedo (plural, come- 
dones). In this stage, acne is a purely functional affec- 
tion ; if we remove the accumulation of sebum in the 
glands and gland-ducts and change — by appropriate 
treatment — the altered character of the secretion, the 
parts resume their normal condition and the disease is at 
an end. 1 If, on the other hand, inappropriate or no 
treatment be adopted, the disease goes on to the next 
stage, — that of congestive or inflammatory acne. Here, 
we find, in addition to the merely functional disturbance 
of the glands, a structural lesion — inflammation, with 
its consequences, — pus-formation and hyperplasia of 
connective tissue. 

The following sketch traces the evolution of an acne 
papule from its stage of comedo : The walls of the 
gland-duct and the immediately surrounding connective 
tissue become compressed, disturbance of the circulation 
and nutrition within a limited area take place, and in- 
flammation follows. At this stage the papule is bright- 
red and painful, usually still showing the black point of 
the comedo at its summit. The inflammation may now 
subside and resolution occur, but usually the process 
goes on to pus-formation. A little drop of pus appears 
in the centre of the papule, which, if evacuated, is found 
to surround the plug of inspissated sebum, the original 
cause of the trouble. 

If the disease is allowed to go on without appropriate 
treatment, that form of acne known as the indurated or 
tubercular acne results. Considerable new formation 
of connective tissue (inflammatory hyperplasia) takes 
place, and those unsightly physiognomies so often seen 
1 See page 20. 



24 Diseases of the Skin. 

in young men and women between the ages of eighteen 
and twenty-five result. There are dark-red blotches with 
firm, brownish nodules, from a split pea to a small bean 
in size, with angry-looking pustules scattered here and 
there over the face, the latter being particularly numer- 
ous on the forehead and cheeks. 

Causation. — Errors in diet, excessive indulgence in 
or abstinence from sexual pleasures, masturbation, con- 
stipation, dyspepsia, eating particular articles of food, 
such as butter and cheese, have all been accused as 
causes of common acne. In vary many individuals 
neither of these conditions, nor even a number of them 
combined being present, produce the disease ; in others 
the disease appears in the absence of these various sup- 
posed causes. 

Although no single functional disturbance or struc- 
tural alteration of any internal organ can be held 
strictly accountable for the causation of acne, the dis- 
ease cannot be attributed exclusively to external causes. 

An epigrammatic professor of New England has 
tersely given the cause of acne in the following propo- 
sition : " The country girl washes her face with sonp, 
and does not have acne ; the city girl abstains from the 
use of soap, and does." Like all epigrams, this is only 
partly true. In the majority of cases of ordinary acne 
the abstention from sonp is doubtless the immediate 
cause of the disease. In other cases, however, this can- 
not be accused of being the cause. 

Acne is so frequentty associated with menstruation 
that every practitioner is familiar with the relationship 
between this skin disease and the uterine and ovarian 
functions. The writer thinks he has observed one form 
of acne which may be classified, and which he has ven- 
tured to term u menstrual acne." It differs from the 



Diseases of the Sebaceous Glands. 25 

ordinary form of acne in being rarely distinctly pustular, 
the eruption coming out in the course of a few days 
preceding or at the beginning of the menstrual period, 
and frequently disappearing with the menstrual dis- 
charge, without proceeding to suppuration. 

Acne vulgaris is usually aggravated during the 
menstrual period, but the eruption of new lesions does 
not cease in the interval, and pustulation is often very 
marked. 

Some women have an eruption of acne papules during 
pregnancy, which disappears after the pregnane} 7 termi- 
nates. The relation between cause and etfect has not 
been satisfactorily explained. The ingestion of various 
drugs, as iodide or bromide of potassium, is frequently 
followed by acne ; the disease disappears on the discon- 
tinuance of the remedy. 

Workmen in tar and petroleum or their products not 
infrequently suffer severely from painful acneiform 
eruptions. Cleanliness and, if possible, cessation of 
exposure to the irritant vapors give relief. 

The only disease liable to be mistaken for acne is the 
papulo-pustular syphilide. In this, however, the erup- 
tion of the lesions is usually acute, and it is not likely 
to be limited to the regions of the bod} 7 usually affected 
by acne. When the syphilitic nature of the eruption is 
suspected, an inquiry into the history of the develop- 
ment of the disease will soon clear up any doubt. 

Treatment. — Internal medication can usually be dis- 
pensed witli in the treatment of acne. Where the con- 
dition of the stomach or bowels seems to demand it, a 
mild mercurial or saline laxative is probably an aid. In 
habitual constipation, cascara cordial, as directed on 
page 19, will often act very happily. Tincture of 
chloride of iron is always indicated when the congestion 

2 B 



26 Diseases of the Skin. 

is considerable, or where there is much pus-formation. 
In strumous or tubercular individuals codliver-oil is a 
useful adjunct to other measures. 

A rigid restriction of diet is not necessary if the 
digestive function is property performed. The consump- 
tion of fatty food, if digestible, should be encouraged. 
Hence, butter, fat meats, or salad-oil should not be pro- 
hibited. In cases of pustular acne, the administration 
of calcium sulphide in doses of T V to J grain is highly 
recommended by some authorities. I have never seen 
any good result follow its use. The same is true of 
ergot, which at the present time enjoys- considerable 
popularity as a remedy in acne. The fluid extract may 
be given in half-drachm doses twice or three times a 

day. 

In some cases acetate of potassium (Formula 23) 
seems to exert a favorable influence upon the course of 
the eruption. 

Arsenic, in doses of T ^ grain (§ milligramme) three 
times a day, is extremely useful in " menstrual acne." 

The local treatment of acne is by far the most impor- 
tant, and in the majority of cases suffices for the cure of 
the affection. 

The indications for the treatment are : (1) to remove 
the accumulation of sebum, (2) to remove the products 
of inflammation, and (3) to restore the normal func- 
tional activity of the parts. 

The first indication is best met by expressing the 
plugs of sebum daily, by means of a watch-key. Select 
a key with a smooth, broad base and wide opening, and, 
placing it directly over the black apex of the papule, 
press the key down squarely upon the skin. A little 
pressure will force the plug of sebum out of the gland- 
duct. This should be done every night. Immediately 



Diseases of the Sebaceous Glands, 27 

after, the face should be washed with warm water and 
soap, allowing the lather to remain on all night. The 
spirit us saponis kalinus may be used. In the morning 
the soap is washed off and the face is dusted with oxide 
of zinc, calamine, or simple chalk or starch powder. In 
simple cases, with a moderately thin epidermis, this is 
all that is necessary, and in three or four weeks the acne 
is cured. I have also had good results from the use of 
EichhofT's resorcin soap. 

In the cases which ma} r , for want of a more definite 
term, be called " menstrual acne," excellent results can 
general^ be obtained by the use of a lotion containing 
sulphuret of potassium and sulphate of zinc (Formula 
24). 

In cases where the epidermis is thick, — a so-called 
coarse skin, — the treatment should be a little more 
active. Here a mixture of sulphur and carbonate of 
potash (Formula 25) should be painted on with a 
camel's hair brush, after the expression of the sebum 
plugs, and allowed to remain on all night. It was first 
recommended by Zeissl,and is certainly a valuable com- 
bination. In the morning, after washing the face, one 
of the above mentioned powders, or a little oxide-of- 
zinc ointment, should be applied. 

After a few days of this treatment, the skin becomes 
slightly reddened and scaly, and, in some cases, an un- 
comfortable sensation of tension or burning occurs. 
Then the sulphur application should be discontinued for 
a few days until the irritation has subsided, when the 
same course should be recommenced. 

If there are many inflammatory papules or pustules, 
incision or puncture with a fine, sharp bistoury gives 
great relief and hastens the involution of the lesions. 
After the puncture the flow of blood should be pro- 



28 Diseases of the Skin. 

moted by a hot-water douche. A basin is filled with 
water as hot as can be borne, and a large, soft sponge 
dipped into it and pressed to the face. This should be 
continued five minutes or so, and is best done at night 
before retiring. It is an especially valuable adjuvant to 
the treatment if the pus-formation is free. 

In cases of indurated acne, the tubercles should be 
freely scarified, and, after the bleeding has ceased, mer- 
curial ointment applied on bits of cloth or leather, and 
allowed to remain on all night. The tubercles may 
also be painted with a strong alcoholic solution of car- 
bolic acid (1 part to 3 or 4 of alcohol) this being re- 
peated every two or three da3 T s. 

In rare cases the treatment above recommended is 
too irritating. A lotion of bicarbonate of soda (3ij 
to Oj) [1 to 60] will sometimes reduce the hyperemia. 
The lotion of sulphuret of potassium and sulphate of 
zinc (Formula 24), diluted with an equal part of water, 
is also useful in these cases. A lotion of resorcin (2 to 
4 per cent.) is often especially beneficial. 

ACNE ROSACEA. 

Acne rosacea, or toper's nose, differs in its clinical 
features, etiology, and its treatment from the condition 
just described. Its subjects are usually individuals 
above the age of thirty ; further, individuals who in- 
dulge to excess in wines or strong liquors — beer-drink- 
ers more rarely have it. It also sometimes occurs in 
young people of defective cutaneous circulation, in 
whom it never gets so marked, however, as in the first 
class of cases. 

Acne rosacea begins as a consequence of frequently 
recurring flushing of the face. The brandy-drinker, 
speaking generally, has a hyperemia of a portion of the 



Diseases of the Sebaceous Glands. 29 

face every time he takes a drink. The vessels gradually 
become permanently enlarged, perhaps increased in 
number, and, in consequence of the local increase in nu- 
tritive material, some connective-tissue hypertrophy 
takes place. The increased circulatory activity of the 
part is accompanied by numerous stases of blood in 
minute areas, which eventuate in small abscesses, the 
acne pustules, accompanying the area of vascular injec- 
tion. In mild degree of acne rosacea, the process stops 
at the formation of diffused red patches. These cases 
are often diagnosticated as " chronic erysipelas." Of 
course, there is no disease properly so called. In cases 
of a more active type, acne pustules will be found scat- 
tered over the red base, upon which also may be noticed 
tortuous, dilated blood-vessels. In the most exa^oer- 
ated condition, we find the nose much enlarged, lobu- 
lated, brown or bluish-red in color, and disfiguring the 
patient very much. 

In the treatment of acne rosacea, the use of wine 
or spirits, if this is the cause of the disease, must be 
forbidden. In those cases where the rosaceous patches 
are due to deficient nutrition, the patient must be placed 
under better conditions. Locally, in the patches of dif- 
fused redness, the application of the alcoholic solution 
of carbolic acid, above recommended (1 part to 3 or 4 
of alcohol), will generalh' give most satisfaction. Where 
there are tortuous and dilated veins in the skin, they must 
be slit up with a line knife and a pointed pencil of nitrate 
of silver drawn through them to cause obliteration of their 
calibre. Where the connective tissue is much increased, 
a plastic operation is sometimes necessary to restore a 
respectable shape to the distorted nose. When pustules 
are present they should be opened with a bistoury and 
the pus evacuated. 



30 Diseases of the Skin. 

In mild cases of rosacea-, a wash of corrosive subli- 
mate, (gr. j to gj) [1 to 500] of diluted alcohol, or of 
resorcin (2 to 4 per cent.), is sometimes all that is 
necessary. 

Occasionally, the redness can be best removed b}' 
painting the skin with a solution of caustic potassa (3ij 
to §j) [1 to 4], and immediately washing it off and ap- 
plying oxide-of-zinc ointment. After a few days the 
zinc and potassium-sulphuret lotion (Formula 24) may 
be applied. 

Dilated vessels may also be obliterated bj' means of 
electrolysis, using 1 to 2 milliamperes of current and 
a fine needle. If the operation is properly performed 
the obliteration is permanent. 

sycosis. 

The characteristic features of non-parasitic sycosis 
are inflammatory papules, pustules, and tubercles, each 
perforated by a hair and occup3'ing especially the region 
of the beard, although the eyebrows, scalp, axillae, and 
pubes may also be seats of the affect ion. 

The following is the usual history of a case of sy- 
cosis : A number of painful reddish papules or pustules 
appear in the beard or moustache, the single lesions 
being each perforated by a hair. The skin around the 
papules or pustules is usually reddened and somewhat 
swollen and infiltrated. In some cases, however, the 
characteristic lesions remain perfect^ isolated ; no ex- 
tension lateral^ of the inflammation taking place. The 
pustules are usually small, flat, or slightly elevated, 
with scant}' contents which they show little disposition 
to discharge, unless punctured or broken by pressure 
or friction. There is often burning and exquisite 
tenderness to the touch ; rarely severe itching. In 



Diseases of the Sebaceous Glands. 31 

cases of long standing the pus has dried into crusts and 
scabs, under which the surface is frequently excoriated. 
At times there are broad, elevated, papillary masses — 
fungoid excrescences — bearing some resemblance to mu- 
cons patches. In other cases there are boils and deep 
abscesses. 

As the disease progresses, the hair-follicles are de- 
stroyed, theliairs, at first still firm in their follicles, fall 
out, and a flat, shiny, reddened, or venated scar results, 
which often strongly resembles the cicatrix remaining 
after the involution of lupus. Recovery from the dis- 
ease rarely takes place without appropriate treatment. 

The etiology of the disease is not established. 
Wertheim believes the primary irritation to be due to a 
disproportion in size between the hair-shaft and the 
hair-follicle. Hebra and Kaposi attribute it to the after- 
growth of a new hair at the bottom of the follicle before 
the mature hair has been shed. The disease is some- 
times caused by the extension into the hair-follicles of 
a more superficial dermatitis, such as eczema. At other 
times it is evidently due to the constant contact with 
the skin of an acrid discharge; for example, a catarrhal 
discharge from the nose, which is frequentlv accom- 
panied by sycosis of tiie upper lip and the parts of the 
nostril studded with the fine hairs called vibrissa?. 
When the inflammation is once lighted up it is kept up 
by the movements to which the hairs are constantly 
subjected. 

The form of sycosis under consideration is not con- 
tagious, is not caused by a parasite, and cannot be 
conveyed from one individual to another through the 
utensils or manipulations of the barber. It is not 
caused by shaving, as the most severe and persistent 
cases are found in persons who do not shave. It is not 



32 Diseases of the Skin. 

very rare, the lighter forms constituting, perhaps, 4 to 
5 per cent, of all forms of skin diseases seen in this 
part of the country. It is most frequently seen in 
individuals between twentj'-five and forty years of age. 

The pathology of sycosis has been shown by Rob- 
inson to be primarily a peri-foliiculitis, progressively 
attacking the follicle itself. There is reason to believe, 
however, that the inflammation may not infrequently 
begin in the follicle and extend secondarily to the peri- 
follicular tissues. 

The diagnosis of non-parasitic sycosis is compara- 
tive^ easy if the salient features of the disease are 
borne in mind. Each papule or pustule is perforated 
by a hair, and the disease is essentially an inflammatory 
affection of the hair-follicle and the immediately sur- 
rounding structures. In fact, S} T cosis bears a nearer 
resemblance to acne than to any other skin disease. In 
acne the sebaceous glands and structures immediately 
adjacent are the seat of the morbid process, while in 
sycosis the hair-follicles and surrounding tissues are 
the parts affected. From the intimate anatomical rela- 
tions of the hair-follicles and the sebaceous glands, it is 
evident that the two diseases must be closely-related 
morbid processes. 

From eczema of the bearded portions of the face 
sycosis is differentiated by the absence of the character- 
istic features of the former disease. In sjxosis there 
is usually no itching or discharge of sticky serum, 
which symptoms especially mark an attack of eczema. 
In eczema there is likewise more infiltration of the skin, 
and the inflammation extends beyond the borders of 
the beard, and may even involve the entire face ; in 
sj^cosis the inflammation is limited to the parts covered 
by thick hairs. It should be remembered, however, that 



Diseases of the Sebaceous Glands. 33 

a long-standing eczema of the beard ma}' result in, or, 
rather, be complicated by sycosis. Even the deep ab- 
scesses, furuncles, and fungous sores may sometimes be 
seen in cases of very intense chronic eczema in strumous 
individuals. 

From parasitic sycosis the differentiation will be 
aided by a hisjoiy of the case. The latter disease usu- 
al ly begins as a ringworm — tinea circinata — and the 
fungus, which is the cause of the disease, can usually be 
found without much difficulty in the scales and affected 
hairs with the aid of a good microscope. In this form 
of the disease the hairs also fall out much earlier than 
in the non-parasitic variety. The hairs are also dry, 
lustreless, broken off, and split at the broken end. When 
the inflammation extends deeper in the parasitic form, 
there are usually numerous deep and very painful ab- 
scesses, which give a knobbed appearance to the lower 
jaw. On opening these abscesses a mucous or muco- 
purulent fluid is discharged. 

The pustular or tubercular syphilide should offer no 
difficult}' in differentiating it from non-parasitic sycosis. 
I have, however, seen two cases where the two diseases 
were present in the same individual, and caused con- 
siderable hesitation in arriving at a conclusion. In 
these cases I found the s} T cosis especially obstinate ; 
both bad a catarrhal discharge from the nose, which 
kept up the irritation of the upper lip, where the dis- 
ease was principally localized. In one of the cases 
the eyebrows were also affected b}' the sycosis. In 
syphilis the generalization of the eruption and the ten- 
dency to destructive ulceration of the lesions, when 
long continued, will enable the diagnosis to be made 
with little difficulty. 

The prognosis of sj^cosis is favorable. It demands, 

2* 



34 Diseases of the Skin. 

however, more personal attention from the physician in 
its treatment than almost any other skin disease. A 
neglect of certain precautions — to be presently pointed 
out — on the, part of either physician or patient, will 
result in almost certain failure to cure the disease, and 
consequent disappointment to the patient and discredit 
to the doctor. 

The important points to be insisted upon in the 
treatment of non-parasitic sycosis are four: shaving of 
the affected parts, puncturing all abscesses and pustules, 
the proper application of appropriate ointments, and 
epilation. I consider it of such importance that the 
diseased spot should be shaved daily, or every other 
day, that I decline to begin the treatment of a case 
unless this advice is followed. There is alwaj^s strenu- 
ous objection on the part of the patient, who urges vari- 
ous reasons for not carrying out this procedure. It will 
be found, however, upon trial, that shaving — if the barber 
is expert and the edge of the razor keen — is not nearly 
so painful as the patient anticipates, and the rapid im- 
provement which follows soon removes all objection to 
the practice. When there is considerable crusting and 
scabbing, the accumulated crusts are first softened by 
the use of sweet-oil, lard, simple ointment, or a poultice, 
and then shaving commenced. In order to facilitate the 
removal of the crusts, the beard can first be shorn with 
scissors. After the face has been shaven, all pustules, 
tubercles, papules, boils, and abscesses should be opened 
with a fine, sharp bistoury, and the discharge of their 
contents and of the blood, which flows prett}* freel}', 
encouraged hy douches of hot water. This is best done 
by dipping a large, soft sponge in very hot water and 
applying it to the diseased surface, continuing this for 
five or ten minutes. When the bleeding has ceased, 



Diseases of the Sebaceous Glands. 35 

some soothing ointment should be applied on cloths and 
bound to the parts. 

Hebra's ointment, or the ointments of ammoniated 
mercury, calomel (5ss-j to 3J) [1 to 8 or 1 to 16], 
yellow oxide of mercury (gr. x-xx to §j) [1 to 24 or 1 
to 48], or oxide or oleate of zinc will be found to answer 
the purpose. The irritation soon subsides, and, on 
daily repetition of this procedure, the face shows 
marked improvement in a few days. When abscesses 
and pustules cease to form, I generally direct the 5-per- 
cent, oleate-of-mercury ointment, and know no other 
application which g^ves such satisfactory results. An 
ointment composed of equal parts of Hebra's and mer- 
curial ointments is also very useful. The diffused red- 
ness that remains can be made to disappear more rapidly 
by an occasional superficial scarification, and the appli- 
cation, twice or three times a week, of a solution of 
carbolic acid in alcohol (1 to 4 parts). The shaving 
must be continued for at least a year after the final 
disappearance of the eruption, for, upon allowing the 
beard to grow again, the disease is exceedingly liable to 
return. 

In many cases of this disease it will be advisable, 
and will hasten the cure, to pull out the hairs from the 
inflamed follicles. It will be found that this procedure, 
if consistently carried out, shortens the duration of the 
disease very materially. It is, however, not so necessary 
in the non-parasitic as in the parasitic form, and it is 
very painful to the patient and trying to the prac- 
titioner. 

In those cases where fungous vegetations occur, they 
may be destroyed by means of caustics or removed by 
the curette. It is only in very rare cases, however, that 
such severe measures are required. In most of the 



36 Diseases of the Skin. 

cases coming under the notice of the physician in this 
country, the aim pie means briefly described will suffice 
for the cure. 

In S3^cosis no* internal remedies are requisite, unless 
there should be disturbance of function of some internal 
organs, — the digestive apparatus, for example, — when 
the appropriate remedies demanded by the case should 
be given. 



ECZEMA. 



GENERAL CONSIDERATIONS. 

Willan and all other English dermatologists, until 
a very recent period, characterized eczema as a vesicular 
disease, accompanied hy the discharge of a sticky, albu- 
minous fluid. Other clinical manifestations of a patho- 
logical condition, apparently similar to that underlying 
the vesicular eruption, were classed as separate and 
distinct diseases. Thus, an itching papular eruption 
was termed lichen, or prurigo ; a pustular eruption was 
impetigo ; and an erythematous or a scaly eruption was 
an intertrigo, psoriasis, or pityriasis. While these 
names still have a place in dermatological nomenclature, 
they have at present, in most cases, a different significa- 
tion to that possessed by them twenty-five }ears ago. 

Hebra, to whom belongs the credit of freeing derma- 
tology from the clogs of artificial classifications and a 
meaningless terminology, recognized the close relation 
of these various manifestations and gave to eczema a 
more comprehensive definition than was given to it by 
the English, French, or early German schools. Accord- 
ing to this definition, eczema is an acute or chronic 
non-contagious inflammation of the skin, manifesting 
itself either in reddened or scaly patches, papules, 
vesicles, pustules, or fissures, characterized in many 
cases by the exudation of a colorless, or yellowish, 
sticky fluid, which dries into amber-colored or brownish 
crusts, and is accompanied by intense itching. 

If we accept this definition of eczema, our conception 

(37) 



38 Diseases of the Skin. 

of the disease becomes at once much more clear and 
simple. We are led to pay attention to the pathological 
condition underlying the morbid process, rather than 
to the manifestations of the disease in any particular 
case. 

It is probable that eczema is, in the majority of 
cases, due to external impressions upon the skin, i.e., it 
is the effect of some local irritant influence, either chem- 
ical or dynamic. There can be little doubt, however, 
that a peculiar predisposition of the skin to take on 
eczematous inflammation is necessaiy before the influ- 
ences mentioned will produce an eczema. Thus, in 
some individuals, the most violent scratching or fric- 
tion, chemical irritants, or changes of temperature or 
moisture, will fail to produce an eczema, while in others, 
any of these influences, even in a mild degree, will pro- 
duce an outbreak of the disease. It is not necessary to 
assume, however, that there exists a peculiar d3 T scrasia 
or diathesis, to which the term eczematous diathesis is 
applicable. The evidence which we have bearing upon 
this point seems to the writer to point to the opposite 
conclusion. 

Although the writer is firm in the conviction here 
expressed, that eczema is mostly due to external physi- 
cal impressions upon the skin, it is not intended thereby 
to exclude altogether affections of internal organs as 
predisposing, or even as exciting, causes of outbreaks of 
the disease. Disorders of the digestive organs, the 
liver, or kidne} T s, and disturbances of the nervous sys- 
tem, seem to have an etiological relation to outbreaks 
of eczema in some cases. 

Hebra speaks of the frequent coincidence between 
eczema and menstrual anomalies. These menstrual 
eczemas, he saj's, are especially localized on the scalp, 



Eczema 39 

face, or lips. In the course of pregnancy, also, eczemas 
frequently appear, generally in the earlier months, and 
continue, in spite of all treatment, to the end of gesta- 
tion. These eczemas are usually localized upon the 
hands. Some women, who have repeatedly been preg- 
nant, are able to determine the presence of pregnancy 
in themselves b} T the outbreak of the eczematous erup- 
tion on their hands. Th. Yeiel reports an interesting 
case, in which the eczema appeared in the third month 
of the patient's third pregnancy, and continued until 
the termination of the puerperal period, when it disap- 
peared without treatment. The eruption was limited 
to the extensor surfaces of the forearms, and recurred 
at five consecutive subsequent pregnancies. 

Hebra also refers to the eczema occurring during or 
after lactation. Sterile women, too, are subject to 
recurrent eczemas, although these may generally be 
traced to some definite lesion of the uterus or ovaries. 
The writer has noticed a form of acute, generalized, 
eczematous eruption, not described by other writers, 
which occurs in association with laceration of the 
cervix uteri. The eruption extends over nearly the 
entire surface, is finely vesicular, and accompanied by 
the most intense itching, fever, and subsequent exfo- 
liation of the epidermis. No treatment addressed to 
the cutaneous disease seems to be of any avail until the 
uterine lesion is remedied. 

Climacteric eczema is referred to b}^ Hebra, and Mr. 
W. Allan Jamieson, in his recent work, devotes some 
attention to this form. He says : " Usually the 
monthly loss has ceased when the eczema appears. 
This form exhibits a proneness to relapse and to the 
recurrence of eczema in certain definite regions for 
many years. More than three-fourths of the cases 



40 Diseases of the Skin. 

occur on the scalp and ears. The extremities also may 
suffer, but the trunk is scarcely affected in any case. The 
scaly and weeping varieties predominate, in contrast to 
the pustular form, .which attacks infants. Itching is 
well marked. From the commencement to the close 
there may be no more than a dry, pityriasis eczema, 
with some loss of hair, liable, however, to be trans- 
formed into the moist form by external or internal 
irritants." 

Eczema is in all cases a curable disease. The pre- 
disposition of the skin cannot, however, be removed by 
any means at present known. Eczema is always liable 
to recur when the irritation is repeated. Hence, while 
the prognosis as to any individual attack is favorable, 
a permanent cure cannot be promised in an}^ case. 

If it be true, as stated above, that eczema is, in by 
far the larger proportion of cases, due to a merely local 
impression of greater or less intensity, it follows, as a 
matter of course, that local measures should suffice for 
its cure ; and we find this to be generally true. 

# 

ACUTE ECZEMA. 

For purposes of clinical description, eczema is 
divided into varieties determined by its duration, its 
localization, and the nature of the primary lesion. 
Hence, we may speak of acute and chronic, general and 
local eczema. 

The varieties depending upon the nature of the pri- 
mary lesion are the erythematous, papular, vesicular, 
and pustular. The acute form of these varieties will 
first be briefly described. 

Acute erythematous eczema most frequently occurs 
in consequence of friction of two opposing surfaces of 
the skin, the action of heat or chemical irritants, or the 



Eczema. 41 

influence of moisture. Hence it is oftenest seen in the 
perineum and on the inner surfaces of the thighs in 
children and adults, and, in fact, wherever the surfaces 
of the skin are habitually in contact, especially if the 
effect of the friction is heightened by heat and decom- 
posing secretions. This condition, known in the ver- 
nacular as " chafe," is often the source of great 
annoyance to both physician and patient, from its 
obstinacy, 

Acute papular eczema is most frequently found on 
the forearms, hands, and feet, and is often due to the 
influence of high temperature of the air (as in aggra- 
vated cases of u prickly heat"), 1 or to persistent 
scratching. The writer has seen it not infrequently 
follow an outbreak of the small, papular urticaria, so 
often localized upon the back of the hand and fingers. 
The severe itching accompanying the urticaria causes 
the part to be rubbed and scratched until the temporary 
disturbance of nutrition has become prolonged, and 
what was at first simply an evanescent affection has 
become one of more permanence. 

Papular eczema frequently runs into a stage of fur- 
ther development of the lesion, and becomes vesicular. 
In other cases the vesicular form is the one first devel- 
oped. This is the old typical form of eczema, — closely 
aggregated, fragile vesicles, which, bursting, exude a 
stick} r fluid that stiffens but does not stain linen. It 
is frequently seen upon the face, ears, and genital organs. 
There is often much serous infiltration of the skin, 
giving the part the appearance of erysipelas. There is, 
however, no pain or febrile disturbance, so marked in 
the latter disease. In er} T sipelas the skin is dark-red 
and shiny, while in eczema the color is much less deep. 

1 See page 9. 



42 Diseases of the Skin. 

In eczema there is also burning, and, in most cases, 
intense itching. 

Pustular eczema is most frequently seen as it 
affects the hairy scalp in children or the hairy regions 
of the face in adults. The pustular character is very 
frequently the expression of a depravement of the 
system. 

Perhaps, in most cases of vesicular eczema, the 
vesicular character of the disease has disappeared when 
the physician is called. The vesicles have burst, and 
their contents have either dried into 3 T ellowish-brown 
crusts, or a red, weeping surface is exposed. This is 
the eczema rubrum of authors, and should be consid- 
ered as a secondary form of the disease. When it 
occurs in parts where the skin is subject to much 
movement, as the flexures of joints, etc., fissures result, 
extending into the cutis, which are very painful some- 
times. This is what is termed in the books eczema 
rim o sum. 

In a small proportion of cases, eczema in all or a 
number of its various forms will be found attacking 
the entire bod3' or its larger surface. In such cases 
the vesicular and pustular forms will be found on the 
face, head, limbs, and genitals ; the erythemato-squamous 
form will be found on the trunk ; the flexures of the 
joints will be occupied by the fissured and weeping- 
forms; while the papular variety will be almost exclu- 
sive^ localized upon the forearms and legs. 

Acute eczema may be limited to certain portions of 
the body, or may extend over the entire surface. There 
are certain sites of predilection where it is often local- 
ized. These are the face, the genital organs, and the 
extremities. 

Acute eczema oftener presents the vesicular char- 



Eczema. 43 

acter than do the chronic cases of the disease. It 
begins suddenly by an outbreak of small vesicles, aggre- 
gated in heaps, the eruption usually having arrived at 
its height in the course of fort} r -eight hours. In the 
most favorable cases, the involution of the process now 
begins, the contents of the vesicles are absorbed, and 
the dried epidermis cast off in whitish scales. In other 
cases the vesicles rupture and the contents dry upon 
the surface in gum-like crusts, which drop off in a few 
days, leaving a slightly reddened but otherwise normal 
surface. 

The eruption of the vesicles is accompanied by red- 
ness and tumefaction of the skin, and subjective sensa- 
tions of burning, tension, and, later, by itching. If the 
surface involved is extensive, the constitutional symp- 
toms of fever may also be present. 

This favorable termination of the affection is, how- 
ever, exceptional. In the majority of cases relapses 
occur, or the action of local irritants prolongs the mor- 
bid process, and the disease, while undergoing certain 
clinical modifications, persists and eventuates in chronic 
eczema. 

Acute general eczema, in which the disease attacks 
almost the entire surface of the body; is rather rare. In 
such cases the various primary manifestations will 
usually be present upon different parts of the surface, 
as above mentioned. 

In acute eczema of the face there is usually great 
oedema of the skin, especially about the eyelids, which 
are sometimes swollen to such an extent as to prevent 
opening the eyes. The redness is also marked, and 
sometimes suggests the appearance of erysipelas, but 
the tense, shiny skin of the latter is not present in 
eczema. The surface is usually uneven, owing to the 



44 Diseases of the Skin. 

presence of papules and vesicles. Upon the ear the 
vesicles are usually present in very great number. 

The genital organs are affected with acute eczema in 
the male oftener than in the female. When the penis is 
attacked the swelling is enormous, and as it occurs very 
rapidly the patient is often greatly alarmed. The organ 
is thickly studded with innumerable little vesicles. In 
the course of a few days the swelling usually diminishes 
and the organ returns to its normal size. There is 
rarely any exudation upon the skin of the penis. 

In eczema of the scrotum the swelling is also very 
great, and the vesicles soon burst and exude a large 
quantity of the characteristic sticky fluid of eczema. 
The decomposition of this exudation gives rise to an ex- 
ceedingly disagreeable odor unless the most scrupulous 
cleanliness is observed. 

Upon the hands and feet acute eczema appears in the 
form of numerous tense vesicles, varying in size from 
a hemp-seed to a small pea. At first there is a " furry " 
sensation, succeeded by itching. When there is much 
swelling the mobility of the fingers and toes is lessened, 
and in some cases entirely abolished, on account of the 
pain and tension. 

The vesicles in eczema of the hands and feet are 
frequently very tense and resistant. They do not burst 
readil} 7 . Sometimes several run together to form a 
good-sized bleb. The itching is usually intense, and is 
often relieved only b}^ fierce scratching. 

CHRONIC ECZEMA. 

In chronic eczema the typical characters presented 
by the acute are very often absent. The persistence of • 
the morbid process gives opportunity for the production 
of various pathological conditions, such as excoriation, 



Eczema. 45 

scaling, crusting, and scabbing. The infiltration of the 
skin increases, the normal pliability of the integument 
becomes lost, and, on pinching up a fold, it resembles 
leather of various thicknesses, rather than living skin. 
In most cases there is considerable discharge and violent 
itching. When the disease continues a long time the 
skin becomes pigmented, especially in lines marking out 
the erasions produced by the finger-nails in scratching. 
Very often the lesions due to scratching extend down 
into the papillary layer, as shown by the dried blood- 
crusts which are found upon the eczematous patch. 

Although chronic as well as acute eczema may affect 
the whole surface of the body or only a limited area, 
it is most frequently observed in certain localities, in 
each of which it presents clinical peculiarities requiring 
separate description. 

In describing these various forms of the disease the 
practical needs of the physician and student will be kept 
in view. 

Only those features will be noted which are necessary 
to arrive at an accurate diagnosis. 

According to its localization, chronic eczema may 
be divided into — 

1. Eczema of the scalp. 

2. Eczema of the face. 

3. Eczema of the trunk. 

4. Eczema of the genitals and anus. 

5. Eczema of the flexor surfaces of joints. 

6. Eczema of the hands and feet. 

7. Eczema of the legs. 

Eczema of the scalp is most frequent in children, in 
whom it is usually present in the pustular form. It 
may also appear as the erythematous or squamous, the 
latter being the variety most frequently seen in adults. 



■46 Diseases of the Skin. 

It may occur in patches or uniformly distributed over 
the entire scalp. The crusts are usually thick, and 
yellowish, greenish, or brownish. They are formed of 
scales, pus, and the secretion of sebaceous glands. If 
strict attention is not paid to cleanliness, the material 
of which the crusts are composed undergoes decompo- 
sition and exhales a very disagreeable odor. The hairs 
are frequently matted together in the scabbing process, 
and the whole scalp may be covered by a large, firm 
crust, under which there are sometimes large collections 
of pus. When eczema of the scalp is neglected, espe- 
cially in children, the head will frequently be found in- 
fested with lice. On the other hand, the irritation 
caused \>y the presence of lice is not rarely the starting- 
point for an eczema. 

Eczema of the scalp sometimes extends beyond the 
hairy part of the head and invades the forehead, ears, 
and back of the neck, in form of a red band, covered by 
whitish, unctuous scales. 

The haij sometimes falls out, but permanent bald- 
ness from eczema is extremely rare. 

Enlargement of the post-auricular and post-cervical 
glands is nearly always present in eczema of the scalp, 
especially in children. 

The table on the opposite page is a modification of 
one given by McCall Anderson, and presents the most 
prominent differentiating points between eczema of the 
scalp, pustular syphilide, psoriasis, ringworm, and sebor- 
rhoea. With its aid, and remembering other essential 
features of the disease, no difficulty ought to occur in 
making a diagnosis. 

Eczema of the face is either limited in extent, or the 
entire face may be attacked by the morbid process. The 
affection ma}^ also be confined to the. hairy portions of 



Eczema. 



47 





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48 Diseases of the Skin. 

the face, i.e., the beard, eyebrows, eyelids, and internal 
surface of the nostril. Eczema of the beard is a pus- 
tular inflammation around the hair-follicles, accompanied 
by burning, itching, sero-purulent discharge, and 
crusting. 

If the inflammation extends deepty into the hair- 
follicles, a condition similar to that known as sycosis is 
established. In the latter the inflammation is limited to 
the hair-follicles and the peri-follicular tissues, while in 
eczema the inflammatory process may extend beyond 
the surface covered with hair. 

In eczema of the eyebrows, the ciliary borders of 
the eyelids and the internal surface of the nostrils, the 
condition is principally a folliculitis. Little flat pustules 
occur, perforated in the centre by a hair. The hairs are 
not loose in the follicles, however, as in parasitic dis- 
eases, but are firmly attached, and cannot be removed 
without causing pain. 

Unna has described a form of eczema under the 
name of seborrhoeal eczema, which usuallj T begins on the 
scalp, and may extend in patches over the entire body. 
It is scaly, has well-defined borders, and usually itches 
but slightly. 

Upon the non-hairy parts of the face eczema usually 
appears in the form of the erythematous, pustular, or 
scaly varieties. The erythematous or erythemato- 
squamous general^ appears upon the forehead, sides of 
the nose or chin, and is general^ accompanied by 
intense itching. 

The eczematous action upon the lips, the angle 
between the nostrils and cheeks, the eyelids, and the 
post-auricular angle is generally manifested by the 
Dresence of one or more fissures, which render move- 
ments of these parts painful, and from which the ec- 



Eczema. 49 

zematous fluid often exudes in considerable quantity. 
The post-auricular eczema is often very persistent. The 
same may be said of fissured eczema of the lips, which, 
when long continued, may cause considerable infiltration 
and hypertrophy of the labial margin. It is also often 
very painful; every time the mouth is opened some of 
the fissures are stretched or torn, and, in consequence, 
laughing, talking, eating, or any movement of the 
mouth causes much pain. 

In children eczema of the face is frequent, and, 
when extensive, has given rise to the popular name 
u milk-crust." The scabs in this condition are formed 
by the drying of the exudate mingled with sebaceous 
secretion. 

The only diseases likely to be mistaken for eczema 
of the face are ringworm and erythematous lupus. In 
the former the patches are always circular or with gyrate 
outlines, with a somewhat pale, scaly centre, and papu- 
lar or vesicular border. In erythematous lupus the 
color of the patch is dark-red or brownish, the scales 
are greasy and adherent, and, when detached, fine pro- 
longations are observed on their under surface. 

Eczema of the trunk may occur in scaly patches from 
the size of a small coin to that of a hand. The patches 
are usually dry and scaly. When chronic there is often 
much infiltration. The itching is usually not very 
severe. 

The disease is often localized about the nipples of 
nursing-women, constituting the troublesome affection 
known as "sore nippies." The nipple is red, swollen, 
with deep, very painful clefts (fissures) running around 
its base. The act of nursing causes the mother exces- 
sive pain. The disease is very obstinate on account of 
the difficulty of giving the parts complete rest. 

3 C 



50 Diseases of the Skin. 

Several } r ears since, Sir James Paget described a 
form of eczema of the nipple which is liable to run 
into cancer of the breast. Microscopic examinations 
by Thin and Wile have shown that the disease is epi- 
theliomatous at a very early stage, if not from the 
beginning. But the fact remains that, in an individual 
predisposed to cancer, any persistent irritation may 
determine the point where the disease will localize itself. 
In the opinion of the writer, cancer of the breast, or 
of any other part, may result as the direct consequence 
of the irritation of a prolonged eczema. It is especially 
advisable, therefore, that mammary eczemas should not 
be neglected, but should be cured as quickly as possible. 

Sir James Paget gives the following lucid account 
of this disease as observed by him in fifteen cases : — 

" The patients were all women, varying in age from 
forty to sixty or more years, having in common nothing 
remarkable but their disease. In all of them the dis- 
ease began as an eruption on the nipple and areola. In 
the majority it had the appearance of a florid, intensely 
red, raw surface, very finely granular, as if nearly the 
whole thickness of the epidermis was removed — like 
the surface of very acute diffuse eczema, or like that of 
an acute balanitis. From such a surface, on the whole 
or greater part of the nipple and areola, there was 
always copious, clear, yellowish, viscid exudation. The 
sensations were commonly tickling, itching, and burn- 
ing, but the malady was never attended by disturbance 
of the general health. 

" I am not aware that in any of the cases which I 
have seen the eruption was different from what may be 
described as long-persistent eczema, or psoriasis, or by 
some other name, in treatises on diseases of the skin; 
and I believe that such cases sometimes occur on the 



Eczema. 



51 



breast, and, after many months' duration, are cured, or 
pass by, and are not followed by any other disease. 
But it has happened that, in every case which I have 
been able to watch, cancer of the mammary gland has 
followed within, at the most, two years, and usually 
within one year. The eruption has resisted all treat- 
ment, both local and general, that has been used, and 
has continued even after the affected part of the skin 
has been involved in the cancerous disease. 

u In practice the question must be sometimes raised 
whether a part through whose disease or degeneracy can- 
cer is very likely r to be induced should not be removed. 
In the member of a family in which cancer has frequently 
occurred, and who is at or beyond middle age, the risk 
is certainly very great that such an eruption on the 
areola, as I have described, will be followed within a year 
or two by cancer of the breast. Should not, then, the 
whole diseased portion of the skin be destroyed or re- 
moved as soon as it appears incurable b}^ milder means ? " 

Prof. McCall Anderson gives a table of diagnostic 
points between Paget's disease and eczema of the 
nipple, which may aid in the differentiation : — 



Paget's Disease. 

1. Occurs in women over forty 
years of age. 

2. Surface affected, in typical 
cases, of brilliant-red color, raw 
and granular-looking after re- 
moval of crusts. 

3. When grasped between the 
thumb and forefinger, superficial 
induration often felt, "as if a 
penny were laid on a soft elastic 
surface and grasped through a 
piece of cloth." 



Eczema of the Mamma. 

1. Generally in women before 
the age of forty ; especially dur- 
ing lactation. 

2. Surface not so red and raw- 
looking, and not granular, but 
often punctated. 

3. Infiltrated, but no indu- 
ration. 



52 Diseases of the Skin. 



4. Edge not abrupt. Never 
elevated. 

5. Obstinate sometimes, but 
yields to treatment appropriate to 
eczema. 



4. Edge of eruption abrupt and 
sharply cut, and often elevated. 

5. Very obstinate ; and only 
yields to extirpation or other 
treatment applicable to epitheli- 
oma generally. 

Around the navel, especially in children, eczema is 
not infrequent. A circumscribed area of the skin be- 
comes swollen and inflamed, and presents a weeping 
surface. The itching is usually veiy troublesome. The 
decomposing secretion often keeps up the irritation for 
a long time. 

Eczema of the genital region presents differences as 
it appears in the two sexes. Occurring upon the male 
organs, chronic, like acute, eczema does not always 
affect both penis and scrotum at the same time. Upon 
the penis the inflammation will generally be noticed to 
occupy the summits of the transverse folds of integu- 
ment when the organ is in the flaccid condition. To 
make this plain it is only necessary to seize the prepuce 
and draw it forward, when the folds will be smoothed 
out and the ridges will be seen as red lines running 
transversely to the organ. Along the inferior surface 
of the penis the skin will be more or less uniformly 
reddened and discharging. The mucous surfaces of the 
prepuce and glands are not attacked by the eczematous 
inflammation. 

Eczema of the scrotum presents itself as a red, dis- 
charging, raw-looking surface, from which the epidermis 
seems to have been stripped off. The discharge is 
sticky, and has an extremely unpleasant odor. Some- 
times the ridges of the corrugated scrotal skin are alone 
affected, and when this is put upon the stretch red lines 
are seen running across the diseased surface in various 
directions. In rare instances, where the disease has 



Eczema. 53 

lasted a long while, the skin becomes greatly thickened 
and infiltrated, producing an appearance resembling 
elephantiasis. In such cases the penis is often almost 
or entirely hidden by the hypertrophied scrotum, which 
rises up and surrounds it. The itching is usually very 
intense, especially at night. 

In the female, eczema of the genitals is usualty local- 
ized upon the greater labia, and may spread thence to 
the thighs or abdomen. The mucous membrane cover- 
ing the lesser labia may also become inflamed. There 
is great swelling, puffin ess of the labia, and increased 
secretion from the mucous membrane, very much re- 
sembling, at times, an attack of gonorrhoea. The itching 
is very annoying. A frequent cause of eczema of the 
genitals is diabetes ; and it will alwa}^s be well to exam- 
ine the urine for sugar in cases of intractable eczema of 
these parts, in both sexes. 

Eczema of the perineum and anus is also very trou- 
blesome. The itching is usually intense, and the affec- 
tion very resistant to treatment. Fissures frequently 
exist, radiating outward from the anal margin, and 
cause intense pain at every faecal evacuation. The fis- 
sures discharge an abundant quantity of serum, which 
rapidly undergoes decomposition and increases the irri- 
tation of the parts. 

Eczema of the flexor surfaces of the joints is one of 
the most painful of this class of affections. The skin is 
greatly infiltrated, and deep fissures, extending down 
into the corium, run transversely across the patch, 
giving great pain at every movement of the joint. The 
eczema, when attacking the joints, is nearly always 
S3 7 mmetrical. Not infrequently the pain, on motion, is 
so great that the patient refrains from moving the joint 
at all, keeping it immovable in the position where it is 



54 Diseases of the Skin, 

most favorable, and often presenting the symptoms of 
ankylosis. The disease, when it attacks these localities, 
cannot be mistaken for any other affection. 

Eczema of the hands and feet most frequently pre- 
sents the vesicular form, the vesicles preserving their 
walls for a considerable period. When it is chronic, the 
fissured condition just described is often found at the 
flexures of the joints. Sometimes the pain from these 
is so great that motion of the fingers and toes becomes 
practically impossible; at other times the epidermis 
of the palms and soles becomes greatly thickened. I 
have seen the epidermis, in cases of eczema of the soles 
of the feet, fully half an inch in thickness. 

Eczema of the legs is one of the most frequent local 
varieties of eczema. It occurs very often in connection 
with varicose ulcers of the lower extremities. It may 
appear as red, shiny patches, over which the skin is 
thickened and tense, or as a red, weeping surface, cov- 
ered with scales and crusts. The itching is usually very 
intense. An artificial dermatitis, which may run into 
eczema, is not infrequently induced in this localit} T by 
scratching, in patients infested with lice. 

In some cases of very persistent eczema of the legs 
the skin becomes very much thickened, hard, and even 
warty, and the condition known as elephantiasis is pro- 
duced. 

DIAGNOSIS. 

The attempt has been made to give a sufficiently 
exact description of the various manifestations of ec- 
zematous inflammation of the skin, to render any detailed 
remarks on its differential diagnosis unnecessary. In 
discussing the local varieties of the disease the cliao;- 
nostic features have also been pointed out. It may still 
be advisable, however, to recapitulate the salient symp- 



Eczema. 55 

toms of eczema, and contrast them with the diseases 
most likely to create doubt as to the diagnosis. 

It will be remembered that, in eczema, the primary 
lesions are erythema, papules, vesicles, and pustules, 
and that usually there will also be one or more of the 
secondaiy lesions, or lesion relics : excoriations, scales, 
crusts, scabs, or fissures. As diagnostic features, must 
be mentioned the discharge — " weeping " — from the 
affected surface, and the itching, which is nearly always 
a symptom of the disease. It is also well to bear in 
mind that eczema produces no ulceration, and leaves, 
after disappearing, no scars. 

The various forms of herpes present some resem- 
blance to, and ma} T be mistaken for, eczema. But in 
herpes there is no itching. If any subjective symptom 
is present at all, it is either burning or pain. In herpes 
the vesicles are large, aggregated in groups, and not 
disposed to break and form crusts. In shingles the 
distribution and arrangement of the vesicular groups 
are so peculiar that no doubt can arise. 

That form of herpes commonly termed " fever-blis- 
ters" is so familiar to every one that it is not likely to 
be confounded with eczema. Sometimes, however, it 
becomes irritated, and runs into a true eczema. 

Another disease which sometimes presents a great 
similarity to eczema is the itch. In this, as in eczema, the 
lesions are multiform, — papules, vesicles, pustules, and 
excoriations being present. In itch, however, the 
lesions are usually separated and scattered over the 
entire body, except the head and face, which are gener- 
ally exempt. In eczema, on the other hand, the 
tendency is to remain localized in patches. In itch, the 
parasitic animal — the itch-mite — which is the cause of 
the disease, can also usually be discovered. 



56 Diseases of the Skin, 

Psoriasis sometimes causes considerable difficulty in 
diagnosis ; but if it is remembered that in this disease 
the affected surface is always dry, that the scales are 
silvery white and seated upon a sharply-defined red 
base, which readily bleeds when the scales are scraped 
off, that it is usually localized upon the extensor sur- 
faces, and that the itching is less intense than in eczema, 
the differentiation can usually be made. 

In lichen, the distinctly papular, dry, umbilicated 
lesions, with the characteristic localization and aggre- 
gation, will enable one to arrive at a diagnosis. 

TREATMENT. 

The treatment of eczema is naturally divisible into 
internal and external. Assuming that the physician is 
imbued with the general therapeutic principle that all 
disturbances of function of internal organs should be 
corrected, if possible, before or coincidently with begin- 
ning the treatment of the skin disease, I will proceed 
to the consideration of the internal remedies appro- 
priate in the treatment of eczema. The first of these 
in importance and usefulness is arsenic. This remedy 
should not be given in acute cases, however ; but in 
chronic papular or scaly eczema it often acts with 
almost specific power. 

The form in which arsenic is given is of some im- 
portance. Fowler's solution (liquor potassii arsenitis) 
often produces nausea, on account- of its taste. This 
tendency is easily overcome by giving the medicine in a 
tablespoonful of sherry wine. The proper dose of 
Fowler's solution, to begin with, is 3 to 5 drops three 
times a day. It should always be taken with or imme- 
diately after meals. The dose should be very gradually 
increased until the limit of physiological tolerance is 



Eczema. 57 

established. It is my practice to add one drop to the 
daily dose every third day until slight puffiness of the 
e} T elids or redness of the conjunctivae conies on. The 
dose should then be slightly diminished, and its effects 
on the disease noticed. It will generally be found that 
in scaly diseases improvement has begun even before the 
limit of tolerance has been reached. The medicine can 
be continued indefinitely without bad effects. No 
danger need be apprehended of " cumulative doses," 
arsenic being rapidly eliminated from the system. 

Pearson's solution (liquor sodii arseniatis) is also 
used sometimes, but has no advantage, so far as I know, 
over the preparation above mentioned. It may be given 
in doses of ten drops, gradually increasing until the 
desired effect is produced. 

Be Valangin's solution (liquor arsenici chloridi) is 
one of the best of this class of preparations. It may 
be made extemporaneously by dissolving one grain of 
arsenious acid in one fluidounce of w T ater, and adding 
half an ounce of dilute hydrochloric acid. This may 
be given in fifteen-drop doses in sweetened water after 
each meal. The dose can be increased by adding one 
drop to each dose every other day. The acid acts as a 
digestive tonic, which is often indicated in diseases 
benefited by arsenic. 

Arsenic may also be administered in the form of 
pills. The pilulse Asiatics^ have long been esteemed as 
an efficient preparation in psoriasis. They consist of 
arsenious acid and black pepper. Formula 27, sug- 
gested by Duhring, ma} T be used. 

The remedy next in value and importance to arsenic 
is iron. It is often of use in the acute form of the 
disease, the best preparation in these cases being 
the tincture of the chloride. In pustular eczemas, 

3* 



58 Diseases of the Skin. 

syrup of the iodide is often of great value. Of the 
most unqualified value is codliver-oil. In so-called 
" strumous " children, where there is much formation of 
pus on the eczematous patch, the lymphatic glands 
enlarged, the skin dry and harsh, codliver-oil may be 
prescribed with the confident expectation of great 
improvement in the patient's condition. 

Eczema has often seemed to me to be connected 
with the excessive consumption of tea, especially if too 
little nutritious food was taken. In such cases milk 
should be substituted for the tea, and endeavors made 
to induce the patient to increase the quantity of beef, 
eggs, and similar articles of food. Fresh air and 
exercise are important adjuvants to any plan of treat- 
ment. 

In many cases of eczema a sharp purge is often of 
value as initiatory to the treatment. A full dose of sul- 
phate of magnesia or calomel will often be useful. In 
other cases, the daily administration of a small dose 
(5j) [4.] of sulphate of magnesia, either combined with 
sulphate of iron (gr. ij) [.12] or quinine (gr. i to ij) 
[.06 to .12], will aid the cure. I often prescribe a com- 
bination of sulphate of magnesia and tincture of chlo- 
ride of iron (Formula 28). 

Calomel in i to \ gr. [.01 to .03] doses three times a 
daj T for 3 to 4 days is often of value. I very often 
prescribe the smaller dose in acute eczemas of children. 

An excellent tonic prescription is one containing iron 
and phosphoric acid (Formula 29). 

Acetate of potassium combined with fluid extract 
of taraxacum, according to Formula 30, will often 
greatly aid local measures in cases of acute eczema. 

Local Treatment. — Of far more importance than the 
internal medication is the local or topical treatment of 



Eczema. 59 

eczema. The " management," as Dr. Bulkley happily 
styles it, of a case of acute eczema will often draw 
upon all the resources of the physician's art. It is not 
only requisite that he shall know what remedies to use, 
but he must know how to apply them and what effects 
to expect. It is often of more importance to know 
what not to do than to have a large formulary at com- 
mand and use it with indiscretion. 

In acute eczema, whether general or localized, almost 
any application ma}^ act as an irritant. The applica- 
tion of simple water may often act injuriously. Sooth- 
ing measures must be exclusively emplo3 T ed. Among 
these the use of dusting-powders may be first men- 
tioned. Combinations of oxide of zinc, starch, precipi- 
tated chalk, lycopodium, or some similar article will be 
useful. If the itching is very severe, black-wash, bicar- 
bonate of sodium (gr. v~x to %)) [1 to 30-50], carbolic 
acid (gr. i-iij to §j) [1 to 200], or simply lime-water will 
give great relief. A lotion containing atropine (gr. j to 
3j) [1 to 500] will promptly relieve the itching, but is 
too dangerous for use, except over small surfaces. 

Starch or bran-baths occasionally give great comfort, 
but it is better to defer their use in acute general eczema 
until the intensity of the inflammation has somewhat 
subsided. After the bath the eczematous surfaces 
should be dusted with one of the powders above men- 
tioned, or some bland, fatty preparation (vaseline, sweet 
almond-oil, lanolin) may be applied. Under this treat- 
ment, with careful attention to the general condition of 
the patient, the disease usually quickly disappears. In 
other cases, however, the morbid process persists, and 
the disease becomes chronic. Here the treatment must 
be different. If the infiltration is not very great, some 
fatt} T application will be most useful. 



60 Diseases of the Skin. 

The most valuable will be Hebra's ointment (For- 
mulae 6, 7), Lassar's paste (Formula 3), oxide-of-zinc 
ointment, vaseline with or without i to 1 drachm of 
calomel to the ounce (1 to 4-8). If the infiltration is 
considerable, these simple applications will not suffice. 
Remedies must be used which will hasten the exfoliation 
of the thickened epidermis and promote the absorption 
of the infiltration in the true skin. 

These remedies are: mercurial ointment, calomel, 
ammoniated mercury, subnitrate of bismuth, tar, car- 
bolic acid, and sometimes chiysarobin or pvrogallic 
^ acid. These may be used either in the form of Ointment 
or lotion, the former in most cases giving the best 
results. 

Methods of use are quite as important as a thor- 
ough knowledge of the medicament to be emplo3 T ed. 
Hence, it will be advisable to take up the treatment of 
the various local forms of eczema seriatim. 

In most cases of eczema, but especially in eczema of 
the scalp, the first point to be attended to is the re- 
moval of the crusts. This is accomplished by covering 
the effected surface thickly with fresh lard, olive-oil or 
almond-oil, and putting on a flannel cap. After ten to 
twelve hours this application is to be repeated, if neces- 
sary, and when the crusts and scabs have been loosened 
the} T are washed off with warm water and soap. Castile 
soap answers best for this purpose. The soap must then 
be thoroughly washed out with clean water and the 
scalp dried with a soft towel. The diseased surface is 
now ready for the application of an ointment. One of 
the best is the white precipitate ointment of various 
strengths (9j-5U to §j) [1 to 4-20], depending upon 
the amount of infiltration present. The red and yellow 
oxides of mercury (gr. iii-x to §j) [1 to 50-150] or calo- 



Eczema. 61 

mel (5ss-j to 5j) [1 to 4-8] may also be used. Tar may 
often be used with great advantage in eczema of the 
scalp. Its offensiveness can usually be modified by 
combining it with cold-cream, using the birch-tree tar 
by preference. Formula 32 is a useful combination. 

Sulphur alone or combined with salicylic acid is also 
of value in some cases of seal}' eczema of the scalp, and 
in seborrheal eczema. Resorcin in 2- to 4-per-cent. 
ointment often acts very happily. 

When eczema of the scalp is due to the presence of 
lice, or if these parasites are present, the part affected 
should be first saturated with petroleum, which promptly 
kills the lice, as well as their ova, or " nits," as they are 
called. It is unnecessary to cut the hair short in treat- 
ing eczema of the scalp. 

Eczema of the hairy parts of the face is often very 
persistent. The first indication, after removal of the 
crusts, is daily shaving, after which an ointment of 
yellow oxide of mercury, or of white precipitate, or one 
composed of equal parts of mercurial ointment and 
simple cerate, kept constantly applied, will bring about 
a cure. If these are too irritant, Hebra's oxide-of-zinc 
or oleate-of-zinc ointments may be tried. I have had 
excellent success with the last named. 

The face is sometimes the seat of an erythematous 
or erythemato-squamous eczema which itches intensely, 
and is often very difficult to cure. A lotion containing 
oxide of zinc frequently gives the best results. Formula 
33 is a good combination. 

This is a much more agreeable application than an 
ointment, and often gives excellent results. An ointment 
containing yellow oxide of mercury and starch (Formula 
34) is also very useful. 

The hair-bulbs of the eyelashes and of the hairs on 



62 Diseases of the Skin. 

the mucous surface of the nostrils — the vibrissae — are 
sometimes the seat of a very persistent eczematous in- 
flammation. In these cases codliver-oil is generally 
indicated. Locally, epilation, followed by the application 
of } r ellow oxide-of-mercury ointment (gr. x to gj) [1 to 
50], or painting the diseased parts with a strong solution 
of nitrate of silver (5*-ij to §j) [1 to 4-8] will often 
promote the cure. Dilute citrine ointment ( 3 i— U to §j) 
[1 to 4-8] is also a good application. 

Fissured eczema of the lips is a very trouble- 
some affection* It is usually very persistent. When it 
lasts a long time the lips sometimes become thickened 
and ectropic. Solution of nitrate of silver (5j to §j) 
[1 to 8] or caustic potassa (3ss to §j) [1 to 15] followed 
by a stiff cerate, " lip salve," containing 1 drachm of 
calomel to the ounce [1 to 8] will in most cases produce 
a prompt cure. 

Chronic eczema of the palms of the hands and soles 
of the feet generally yields promptly to appropriate 
treatment. If the epidermis is very much thickened it 
may be first softened by soaking in hot water rendered 
alkaline with carbonate of soda, or friction with Hebra's 
soap-tincture (Formula ID), and then ail ointment made 
of equal parts of mercurial and Hebra's ointments con- 
tinuous^ applied. The cure is sometimes very rapid, 
the infiltration and fissured condition of the skin disap- 
pearing as if by magic. Other local measures will 
rarel} T be needed. 

Eczema of the dorsal and lateral surfaces of the 
fingers is, however, very troublesome. It often attacks 
laundresses, cooks, seamstresses, and grocers, the nature 
of whose occupations prevents the continuous applica- 
tion of a remedy. The itching is usually intense.. It 
often requires applications of solution of caustic potassa 



Eczema. 63 

(3j to 5j) [1 to 8], followed Ivy Hebra's ointment, or 
ammoniated mercury ointment. 

India-rubber gloves or " finger-stalls " are often of 
great service in the treatment of these chronic eczemas 
of the hand and fingers. They act by confining the 
moisture, and thus macerating and softening the dis- 
eased epidermis. 

Eczema of the joints is a very painful affection. The 
diseased skin is divided into little squares or lozenge- 
shaped spaces by fissures of greater or less depth, running 
in various directions. Every motion of the joint causes 
intense pain. It is often found in the popliteal region, 
and from its painfulness may interfere with locomotion. 

Hebra's ointment alone, or combined, when there is 
much infiltration, with equal parts of mercurial oint- 
ment, will generally cause the disease to yield. Appli- 
cations of the nitrate-of-silver or canstic-potassa solu- 
tions are sometimes necessaiy, however. 

Eczema of the legs is often dependent upon a varicose 
condition of the veins of the part. In these cases proper 
support must be given to the dilated vessels before 
much good can be accomplished by applications directly 
addressed to the disease. If the case is very chronic 
and there is much infiltration of the skin, painting with 
the potassa solution (3ss-j to |j) [1 to 8-15] or fric- 
tion with Hebra's tincture of soap, or Bulkle} 7 's liquor 
picis alkalinus (Formula 35) should be used. 

This should precede the application of Hebra's oint- 
ment, carbolic-acid ointment, or ointment of ammoniated 
mercury, carbonate of lead, oleate of zinc, or oxide of 
zinc. The ointment must be kept on by a well-applied 
flannel roller-bandage (made of " Domette " flannel). 
After the cure is complete, an elastic stocking should be 
worn to give the superficial veins proper support. 



64 Diseases of the Skin. 

In eczema of the legs, the rubber bandage is often 
applied, but, unless there is considerable infiltration of 
the skin, it may do more mischief than good. The 
cases in which the rubber bandage is applicable must be 
carefully selected. 

Chronic eczema of the scrotum often tests severely 
the endurance of the patient and the therapeutic re- 
sources of the practitioner. In some cases the eruption 
will rapidly disappear under a simple calomel ointment. 
In others, a tar ointment or a dilute solution of liquor 
picis alkalinus will have the desired effect. These are 
the cases which John Hunter must have had in mind 
when he said that skin diseases may be divided into 
three classes': those that sulphur will cure, those that 
mercury will cure, and those the devil himself cannot 
cure. The experience of most practitioners will prob- 
ably place chronic eczema of the scrotum in the last- 
mentioned class. 

Unless there is considerable infiltration of the skin, 
only mild applications, such as oxide of zinc, oxide of 
mere my, or Hebra's ointments, should be used. The 
itching yields better if a little tar or carbolic acid is 
added to the ointment. In some cases, where there is 
little thickening and redness, and only slight scaling, a 
weak sulphur and salicylic-acid ointment will prove suc- 
cessful. In obstinate cases the possibility of diabetes 
should be borne in mind and the urine carefully ex- 
amined for the presence of sugar. 

A variefcj 7 of eczema which attacks the scrotum, 
perineum, and insides of the thighs, with a moist or 
scaly surface and a well-defined border, is not rarely 
seen. This is really a parasitic affection, and requires 
parasiticide treatment. 

This disease is often very obstinate, and many reme- 



Eczema. 65 

dies may be used in turn with little or no good effect. 
The application of strong sulphurous acid once a day, 
as recommended by Bulkley, or of a solution of bichlo- 
ride of mercury in tincture of myrrh, as recently advised 
by R. W. Taylor, will generally give good results. I 
have used, instead of the tincture of myrrh, the com- 
pound tincture of benzoin (Formula 36), which is, I 
think, better than the former. 

Eczema of the nipple often yields quickly to an ap- 
plication of simple cerate containing one drachm of calo- 
mel to the ounce [4„to 30.]. In more obstinate cases the 
nipple may be painted with a pigment composed of one 
drachm [4.] of oil of cade to one ounce [30.] of collodion 
or liquor gutta-percha. This is also a useful application 
in fissured eczemas of the lips. Salol dissolved in ether 
and collodion (Formula 3T) is also recommended in 
eczema and fissure of the nipple. 

• C 2 



INFLAMMATIONS OF THE SKIN 



The class of inflammations of the skin includes a 
number of affections which cannot be strictly termed 
inflammatory, but which are so near, and sometimes 
even overlap the border-line, that they cannot well be 
excluded. These affections are the erythemas, urticaria, 
and some of the drug eruptions. 

The exanthemata are not skin diseases proper, but 
specific fevers with local cutaneous manifestations. 
They rarely come under the notice of the dermatologist, 
except in cases of doubtful diagnosis, and the cutaneous 
lesion scarcely ever calls for local treatment. They will 
not receive notice in this work, therefore, be\ond point- 
ing out the differential diagnosis where necessary. 

In classifying the erythemata and urticaria with the 
inflammatory diseases, I am in accord with the expressed 
judgment of the representative body of American der- 
matologists. 

ERYTHEMA. 

Erythema is a redness of the skin due to excess of 
blood in the part. It may be transitory or lasting. 
The hyperemia ma} 7 be active or passive. In the former 
the skin is usually bright red in color, and the temper- 
ature slightly elevated. Sometimes there is also slight 
swelling, indicating exudation of serum, and, perhaps, 
cell-proliferation ; in other words, inflammation. In 
passive hyperemia the color is of a deeper red, brown- 
ish or bluish, and there is no local elevation of temper- 
ature. There ma} 7 at times be slight haemorrhages into 
the dermal tissues. 
(66) 



Inflammations of the Skin. 67 

The erythemas are clinically divided into the con- 
gestive and exudative. In the former the redness is due 
merely to a temporary accumulation of blood in the 
part. Jn the other forms the redness is more perma- 
nent and accompanied by exudation and local altera- 
tions of nutrition. These are the exudative erythemas, 
and constitute the transition forms to the inflammations 
proper. 

Congestive erythemas may either be idiopathic or 
symptomatic. The idiopathic forms are all produced 
either by traumatism, heat, or irritants acting on the 
skin. Thus, we have a redness of the skin from con- 
tinned pressure upon any part, as, for example, under 
belts, girdles, garters, or upon the tubera ischii after 
sitting for a length of time. A semicircle of redness is 
frequently seen upon the forehead from a tight hat-band. 
Moderate chafing also exhibits an example of traumatic 
erythema; when it becomes more severe, it is apt to run 
into eczema. Light degrees of sunburn give examples 
of the erythema produced by heat. 

A class of remedies termed rubefacients in works 
upon therapeutics give rise to the erythema from irri- 
tants. The ingestion of certain drugs also frequently 
causes an erythematous eruption. 

A more important group of hyperemias (congestive 
erythema) is that of the symptomatic. It is a common 
observation that many febrile, and also non-febrile, dis- 
eases are accompanied at times by circumscribed red- 
ness of the skin. 

Typhus and t3 r phoid fever, rheumatism, small-pox, 
and vaccinia may be accompanied by an eruption of 
rose-colored spots. The} r are important in a diagnostic 
point of view. In many of the diseases of children, 
especially disorders of the digestive organs, fugitive 



68 Diseases of the Skin. 

hyperemias may be observed. At times they may bear 
considerable resemblance to an eruption of measles or 
scarlatina. 

In small-pox epidemics a peculiar hj^peraemia is 
sometimes observed, occurring contemporaneously with 
the primary fever, i.e., two or three days before the 
appearance of the eruption. This is, consequently, of 
considerable importance as a diagnostic point. An 
eiythematous efflorescence appears upon the abdomen 
and upper part of the thighs, having the form, when the 
thighs are adducted, of a truncated pja-amid with the 
base upward ; the hyperemia is bounded by an im- 
aginary transverse line at the height of the umbilicus 
and another about two inches above the knees, and con- 
necting the extremities of these lines by two others, 
running parallel with the loins. 

The operation of vaccination — or, more properly, 
the vaccine disease — is sometimes accompanied by an 
eruption of rose-colored spots, — the so-called roseola 
vaccina ; it is of no importance, and requires no treat- 
ment. Exceptionally, however, it runs into a derma- 
titis (erysipelas), and may then become a serious 
complication. 

The treatment of simple erythema is merely symptom- 
atic. An evaporating and cooling lotion, as cologne- 
water, or a lotion of bicarbonate of sodium, half an 
ounce to the pint of cool water (1 to 32) will be all that 
is required. When the hyperemia approaches the in- 
flammatory stage, as in erythema intertrigo (chafing), 
the following measures will give satisfactory results : 
The parts should be kept clean and as dry as practi- 
cable. Portions of the skin ordinarily in contact and 
rubbing against each other, as in the perineal region, 
between the buttocks, in the axillae, under pendulous 



Inflammations of the Skin. 69 

mamniffi, etc., should be kept separated by pledgets of 
lint, dusted with oxide of zinc or precipitated chalk. 
Where the redness is intense, and there is much heat or 
tingling, black-wash, applied on soft cloths and fre- 
quently renewed, is an admirable application. Formula 
38 will often prove useful. 

All the exudative erythemas may conveniently be 
grouped together under the collective title erythema 
multiforme. The sub-varieties are the papular, bullous, 
and nodose forms. A large number of intermediate 
forms have been described, but they are so manifestly 
merely stages of the affection that they will not be de- 
scribed as separate diseases. Erythema multiforme is 
characterized by its location, which is almost always on 
the backs of the hands and feet, extending in some 
cases up the arms and legs, and even in rare instances 
invading the entire bod} r . The latter is especially liable 
to occur in the course of rheumatism, diphtheria, and 
other febrile diseases. 

The papular form of erythema multiforme is the most 
frequent. The papules are small, dark red, sometimes 
shading into brown, and flattened. In a few days, usu- 
ally, the reddish color gives place to varying shades of 
brownish, greenish, bluish, even black, these depending 
upon the exit of the coloring matter of the blood during 
the height of the process. The eruption is frequently 
the source of much alarm, but in itself has no signifi- 
cance. The papules are usually interspersed with ery- 
thematous spots, rings, gyrating lines (where two or 
more rings have run into each other), tubercles, and 
sometimes vesicles or large blebs. These sometimes 
simulate an eruption of pemphigus (q. v.). 

The nodose form of erythema multiforme consists 
of circumscribed swellings of various sizes, from a bean 



70 Diseases of the Skin. 

to a lien's egg, or larger, mostly situated upon the ante- 
rior surface of the leg, but also upon the face and other 
portions of the body. They are at first red in color, 
but afterward become bluish, greenish, or purplish, 
resembling very closely a bruise. They are painful and 
sore to the touch. They never suppurate. Sometimes 
the swellings closely simulate syphilitic gummata. but 
they never break down, as these latter formations do. 

The treatment is simple. Pain or burning may be 
relieved by a cooling lotion. In the generalized forms 
of erythema multiforme the patient should always be 
carefully examined in order to determine whether the 
eruption is symptomatic of grave internal diseases. It 
has been observed in connection with rheumatism, with 
cardiac complications, pneumonia, diphtheria, and 
Brigkt's disease. 

URTICARIA. 

Nettle-rash is an acute eruption accompanied by 
tingling, burning, and itching. 

The typical form of this eruption is a broad, flat, 
slightly elevated papule, with a bright-red border and a 
whitish or lighter red centre. This lesion is termed a 
wheal, and is the characteristic feature of the affection. 
The wheal is, however, not the only form in which the 
eruption of urticaria manifests itself, as the efflorescence 
may be composed in great part, or entirely, of small 
papules, linear elevations, or considerable tuberosities. 
from the size of a hazel-nut to a lien's egg. The size 
of the lesions clearly depends simply upon the amount 
of exudation and. perhaps, upon a greater or less 
predisposition in the skin to irritative action of this 
character. The eruption generally begins with great 
suddenness, is sometimes accompanied with febrile 
symptoms, and frequently disappears as suddenly as it 



Infla m malions of th e Skin. 7 1 

came. Itching and burning are characteristic S3^mptoms 
of the eruption. Sometimes the top of one or more of 
the wheals is occupied by a vesicle. This simply de- 
pends upon the increased effusion of serum, and, beyond 
slightly changing the appearance of the eruption, has 
no significance. In rare cases, especially in delicate, 
irritable skins, pigmented spots, yellowish, greenish, or 
brownish in color, ma} T remain for some time to mark 
the sites of the eruption. 

Anatomically, the wheal consists of an exudation of 
serum into the Malpighian layer of the epidermis and 
the upper layers of the corium, with a limited annular 
hyperemia due to a dilatation of the smaller vessels in 
the marginal zone of the wheal. 

The causes of urticaria are both external and in- 
ternal. In addition to the irritating influence of plants 
of the nettle family, and which has given to the affec- 
tion one of its popular names, nettle-rash, the external, 
direct, or traumatic causes of urticaria are : the bites of 
the various insects, — lice, mosquitoes, fleas, bed-bugs, — 
contact with larvae of various species of lepidoptera, 
and in some cases scratching or friction of the skin. 

It is, however, only in persons with a peculiar irrita- 
ble condition of the skin that urticaria of any great 
extent follows these influences. In such cases a single 
flea-bite may give rise to the most intense pruritus and 
general urticaria. In children it is frequently caused 
by the irritation of the bites of lice or bed-bugs. In 
these instances, remedies which do not comprise removal 
of the cause have no effect on the duration of the 
affection. 

The most frequent causes of urticaria are internal or 
indirect, the eruption on the skin being probably a reflex 
effect of an irritation of some internal organ. In by 



72 Diseases of the Skin. 

far the majority of instances it is due to irritation of 
the stomach or other portion of the intestinal canal. 
The ingestion of certain articles of food, especially 
shell-fish, pork, cheese, strawberries, and raspberries, or 
the administration of various medicinal agents, especially 
terebinthinate remedies, produce in certain predisposed 
individuals an abundant outbreak of urticaria. The 
eruption is frequently accompanied by symptoms of 
decided gastro-intestinal irritation, as vomiting and 
purging, sometimes choleriform in character. Not in- 
frequently catarrhal jaundice is present in these cases, 
and seems to intensify the pruritus, probably by a direct 
irritation of the cutaneous nerves, due to the circulation 
of biliary matter in the blood. 

Very often the urticaria can be ascribed only to a 
peculiar id ios}^^!^^ with reference to the articles of 
food causing the eruption, while at other times d}'Spep- 
sia, or, rather, gastric irritability, seems to be present. 
In these cases the individual is compelled to limit him- 
self to a very short diet-list, any deviation from which 
is sure to brino- on an attack of acute indigestion and 
urticaria. This latter is especially liable to be the case 
in the frequently-recurring, almost chronic urticaria, 
so often seen in young children. 

In persons suffering from the gastric irritability here 
referred to an eruption of little, pinkish, intensely itch- 
ing papules frequently occurs, accompanying attacks of 
acute indigestion. This papular eruption is primarily 
nothing more than an urticaria, but in consequence of 
the continual scratching which it induces eczema results 
secondarily. The primary eruption is frequentty not 
recognized, and hence the eczema is too often believed 
to be caused by the gastric derangement, leading to its 
irrational treatment. 



Inflammations of the Skin. 73 

If, in consequence of the administration of an alkali, 
or a small dose of calomel, the urticaria ceases, its 
cause being removed, the eczema generally gets well 
without further treatment, unless it has become chronic, 
when proper local measures should be instituted. 

A number of functional or organic disorders of the 
female sexual apparatus are sometimes complicated by 
chronic urticaria, but as these troubles are usually 
accompanied by gastric derangement, the latter may, 
in most of the cases, be the exciting cause of the 
eruption. 

Mr. Lawson Tait has recently reported a number of 
cases in which urticaria came on after abdominal sec- 
tion. Hebra first called attention to the frequent asso- 
ciation of urticaria with uterine disorders. Scanzoni 
has likewise pointed out this coincidence. 

In malarial regions intermittent urticaria, with or 
without febrile symptoms, is sometimes seen. Emo- 
tional disturbances, such as fright, anger, or great 
sorrow, appear not infrequently to stand in a causative 
relation to urticaria. Moreover, many well-defined ner- 
vous disorders are complicated with the same affection. 
It must also be confessed that cases occur for which no 
cause can be discovered. 

The prognosis, so far as life is concerned, is favor- 
able. If the cause of the disease can be discovered and 
removed, it usually requires no further treatment. 
Yevy often, however, it becomes chronic and persistent, 
either from non-recognition of the cause or because the 
latter cannot be removed. 

The diagnosis is easy. Remembering the charac- 
teristic lesion of urticaria, and the subjective sensations 
of itching or burning always present, no mistake is 
liable to occur in differentiating this from other cutane- 

4 D 



74 Diseases of the Skin. 

ous diseases. To discover the cause is, however, as has 
been before pointed out, often most difficult and unsat- 
isfactory. 

The pathology of urticaria is one of those unsettled 
problems which abound not only in dermatolog3 T , but 
also in other special fields of medicine. Chemical exam- 
inations of the urine have shown that there is frequently 
a deficient elimination of urea and uric acid in cases of 
urticaria. It has been supposed by some that the reten- 
tion of these excretoiy matters in the blood produces 
an irritating effect upon the peripheral nerves in the 
skin, and so gives rise to the development of the char- 
acteristic eruption. It has also been supposed that a 
similar irritation may be produced in consequence of 
the resorption of some products of decomposition in the 
alimentary canal. While both these theories ma}^ be to 
a certain very limited degree true, they explain but few 
of the cases. 

The nature of urticaria has long been held to be 
neuropathic, but only the most recent discoveries in the 
ph} T siology of the nervous system have furnished some 
sound and reasonable basis upon which to build a safe 
and satisfactory theory. 

Without going into the history of the researches 
upon the vaso-motor nerves, it will suffice to say that 
it is now pretty generally admitted that there are two 
sorts of vaso-motor nerves, antagonistic to each other 
in their effects upon the vessels, — the vaso-constrictors 
and vaso-dilators ; that these nerves originate in ganglia 
situated in the spinal cord and medulla oblongata, and 
that the\ r leave the cord by the posterior nerve-roots. 
This important disco very contradicts Bell's law, that 
onl}^ afferent nerves are contained in the posterior 
nerve-roots, and demonstrates that these roots also con- 



Inflammations of the Skin. 75 

tain efferent nerves. Whether the vaso-motor nerves 
are really sensitive nerve-fibres, or whether these bun- 
dles contain an independent set of vasal nerves, is not 
yet known. „ 

It has been further demonstrated that a reflex eon- 
traction or dilatation of the small blood-vessels is 
possible, and, furthermore, that certain systems of ves- 
sels act in a manner antagonistic to each other. This 
antagonism has been particularly studied in relation to 
the vessels of the skin and of the abdominal viscera. 
It has been found, namely, that when the constrictors 
control the abdominal vessels, the dilators act upon the 
vessels of the skin. 1 The latter is not to be ascribed to 
a passive dilatation in consequence of the increased 
blood-pressure, a complementary dilatation, so to speak, 
but active and due to a stimulant effect, possibly reflex, 
upon the vaso-dilators of the skin. 

The circumstance pointed out by Strieker, and be- 
fore referred to, that irritation of sensitive nerve-fibres 
causes dilatation of vessels, seems to point to a solution, 
namel} 7 , that certain sensitive nerve-fibres possess, in 
addition, the function of vaso-motors. The action of 
the vaso-dilators cannot always be due to reflex impres- 
sions, because the effect is produced upon a very limited 
section of the skin, and in other cases is produced at 
the site of the irritation. Examples of this are seen in 
the circumscribed production of urticaria in consequence 
of contact with nettles, bites of insects, etc. ; but I can- 
not doubt that general urticaria, the accompaniment of 
gastric irritability, is due to a reflected impression upon 
the vaso-motor centres themselves. 

1 Strieker (Allg. Pathologie, p. 216) says: "There is reason to believe 
that in the nervous centres the constrictors for the vessels of the abdom- 
inal viscera and the dilators for those of the skin are more easily excited 
than their antagonists." 



*T6 Diseases of the Skin. 

Treatment. — Notwithstanding the frequency of urti- 
caria, the therapeutics of the affection are in a very 
unsatisfactory state. When the eruption is the result 
of irritating ingesta in the stomach or intestinal canal, 
an emetic or brisk purge will in most cases promptly 
relieve the affection. As an emetic, I decidedly prefer 
the sulphate of zinc (20 grains [1.3] in water), or fluid 
extract of ipecac given in a little syrup. Except in 
young children, however, such acute cases do not very 
often come into the hands of the practitioner, and 
almost never into those of the specialist. 

When, however, the disease has become chronic, or 
is very frequently recurring, it gives a great deal of 
annoyance both to the patient and physician. The 
cause must be sought out and removed, if possible. It 
is frequently necessary to go over the patient's func- 
tions, one by one, to rigidly revise the diet-list, regulate 
the bowels, stimulate the action of the liver, if this 
seems necessary. The urine should be examined, and 
any abnormality of this secretion corrected, if possible. 
The saline laxatives and diuretics will find frequent 
application in these conditions. In cases where the 
eruption shows a regular periodicity in its recurrence, 
full doses of quinine sometimes have a prompt effect, 
and, if it fails, arsenic may be tried and sometimes 
found successful. 

Recently, several of the later remedies have been 
tried and reported favorably. Thus 20-grain doses 
[1.3] of salicylate of sodium three times a day have 
been followed by prompt cure in a number of cases of 
more or less persistent urticaria. My own experience 
with this remedy is favorable. Schwimmer reports suc- 
cess in similar cases with ^-grain [.001] doses of atro- 
pine sulphate. Still more recently, Pick has reported 



Inflammations of the Skin. 77 

brilliant results with pilocarpine. The eruption disap- 
pears as soon as the . effect of the remedy upon the 
sweat glands becomes apparent. It may be used hypo- 
dermatically in doses of | grain [.01], or half-drachm 
[2.] doses of fluid extract of jaborandi may be given. 
It promises to be worthy of trial. Some years ago I 
treated, experimentally, several troublesome chronic 
cases with drop doses of balsam of copaiba, which I 
had seen recommended in some journal. My success 
with this remedjr was not uniform, however, and I should 
be disposed to give the jaborandi or salicylate of sodium 
the preference. The local treatment is sometimes a 
matter of importance. Any spirituous lotion, sol. car- 
bolic acid 1 to 2 per cent., or black-wash may be used. 
I have found the least disagreeable antipruritic lotion 
to be one consisting of 1 drachm of benzoic acid to a 
pint of water [1 to 130]. 

SIMPLE INFLAMMATIONS OF THE SKIN. 

The inflammatory diseases included under this title 
are divided into such as are due to the influence of 
mechanical violence (dermatitis traumatical), from 
chemical irritants (dermatitis venenata), from extremes 
of temperature (dermatitis calorica), from the inges- 
tion of certain drugs (dermatitis medicamentosa) , and 
those due to some profound neurotic or vascular dis- 
turbance (dermatitis gangrenosa). 

Traumatic dermatitis is due to local mechanical 
injury. It includes inflammations from excoriations, 
bites and stings of insects, bruises, lacerated wounds, or 
prolonged pressure on a part. 

The treatment consists primarily in removal of the 
cause, if still acting, and the application of such meas- 
ures as will reduce the inflammation. Cold water, astrin- 



78 Diseases of the Skin. 

gent lotions, and, if the deeper structures have been 
exposed, antiseptic dressings may be used. 

Dermatitis from chemical irritants locally applied is 
not infrequent. Cantharides, croton-oil, tartar emetic, 
mercurial compounds, turpentine, arnica, mustard, 
petroleum, poison-ivy, poison-sumach, strong acids and 
alkalies, acrid secretions or discharges from wounds or 
ulcers may all cause dermatitis of varying degrees of 
intensity. All the different lesions characteristic of 
inflammation of the skin may be present. 

The dermatitis from poison-vine or poison-sumach is 
relatively frequent in the spring and autumn. Contact 
with these plants produces an intense inflammation 
characterized by redness, great swelling, burning, and 
itching. There is usually an abundant eruption of vesi- 
cles, which break and pour out a profuse, sticky, serous 
secretion. The hands, face, and genital organs are most 
frequently affected. 

The diagnosis is usually easv, eiysipelas and acute 
eczema being the only diseases that can be mistaken 
for it. In the former there is absence of itching and 
vesiculation, and the fever is usually high. In acute 
eczema the outbreak is usually rarely so violent, except 
in young children, in whom the action of the poison 
can generally be excluded. Eczema also has usually a 
different localization from the poison-vine eruption, 
being rarely limited to the same portions of the surface 
as the latter. 

There is a popular tradition that when an individual 
once suffers from a poison-vine eruption it will return 
annually for seven years, without renewed exposure. 
This is an error. Most people w T ho suffer from the 
eruption every 3^ear contract the same after being again 
exposed to the cause. 



Inflammations of the Skin. 79 

The treatment must be directed to subduing the 
inflammation and relieving the subjective symptoms. In 
the poison-vine eruption, lotions of sulphate of zinc 
(3ss to water Oj) [1 to 250], or of bicarbonate of soda 
(3j to Oj) [1 to 16], or black wash generally give prompt 
relief The first named is said by Hardaway to be 
almost a specific. Van Harlingen recommends fluid ex- 
tract of grindelia robusta (5U to water §j) [1 to 4], 
Tincture of lobelia with an alkali (Formula 39) is also 
highly recommended. 

All of these lotions are to be applied to the affected 
surface on cloths kept constantly wet with the prepara- 
tion. Diving-powders, such as prepared chalk, starch, 
or orris-root, may also be sometimes used to advantage. 

The inflammation due to arnica or any of the other 
articles mentioned above generally jields quickly to 
mild astringent lotions or ointments (oxide-of-zinc oint- 
ment, Hebra's ointment) or dusting-powders of starch 
containing camphor, oxide of zinc, or calamine. 

Dermatitis from extremes of temperature includes 
both inflammations from excessive heat (burns) and 
from extreme cold (frost-bite). 

Burins are usually divided, according to the intensity 
of the acting cause, into three degrees. In the first 
there is redness, some pain and swelling. In the second 
degree vesicles or blebs form upon the inflamed skin, 
accompanied usually try severe pain. In the third degree, 
necrosis of tissue to a varying depth occurs. If the 
burn is very severe or of great extent, there is usually 
great depression of sj^stem and the patient may die of 
shock. In other severe cases the patient survives the 
shock, but succumbs to exhaustion, septic absorption, 
embolism, or pneumonia. The prognosis in all severe 
grades of burns is grave. 



80 Diseases of the Skin. 

The treatment of burns of the first degree consists 
simply in relieving the pain. For this purpose nothing 
is superior to a lotion of bicarbonate of soda, applied 
on soft cloths which are kept constantly saturated. 
The same application is useful in burns of the second 
degree. The blisters should be punctured, and the de- 
nuded epidermis protected by absorbent cotton or lint. 
Dusting-powders of starch, carbolized oil, or a paste of 
carbolic acid, vaseline, and prepared chalk will be of 
value. 

In the profound burns of the third degree, the re- 
moval of the necrotic masses should be promoted by 
poultices or warm-water dressings rendered aseptic with 
carbolic acid, or solution of sodium hypochlorite. The 
denuded surfaces should then be dusted with iodoform 
or dressed with boracic or carbolic-acid ointment. Care 
should be taken to prevent the formation of contractile 
or hypertrophic scars. 

Frost-bite. — Like burns, frost-bites also manifest 
themselves in different degrees. The first degree, or 
erythematous frost-bite, is popularly known as chilblain. 
The parts most frequently attacked by chilblains are the 
toes and fingers. The nose and ears are also sometimes 
affected. The affected spots are bluish-red, slightly 
swollen, sometimes painful, but most frequently annoy 
by their persistent burning and itching. They often 
return in successive winters. Sometimes the epidermis 
is destroyed by rubbing or scratching and a superficial, 
painful ulcer remains. 

In the second stage of frost-bite, blebs with serous 
or bloody contents form, under which a deep ulcer is 
often found. The healing of this generally takes place 
very slowly. 

In the third stage, deep sloughs take place, which 



Inflammations of the Skin. 81 

usually require amputation of the affected extremity. 
If the necrotic masses are not removed by the surgeon, 
septic absorption is liable to occur, and the patient dies 
of septicaemia or p} T 8emia. 

The treatment of acute frost-bite — that is, during 
the action of the cold — usually consists in rubbing the 
frozen part with snow or coldw T ater until the circulation 
is re-established. In the author's opinion, however, it 
would be more appropriate to immerse the frozen part 
in hot water in order to restore promptly the circulation 
of blood. Afterward, astringent lotions of acetate of 
lead, sulphate of zinc, or alum may be used. 

In chilblains, collodion painted on the spot is fre- 
quently of service. A dilute solution of nitric acid 
(§ij to Oj) [1 to 8] is also recommended. A camphor- 
ated paste (Formula 40) may also be used. 

A mixture of equal parts of ichtliyol and oil of tur- 
pentine, painted on with a camel's hair brush, is highly 
recommended by a recent German writer. 

In the second stage the sloughing bases of the blebs 
should be touched with a strong solution of nitrate of 
silver (5j to §j) [1 to 8] and afterward dusted with 
iodoform or powdered boracic acid. In the third stage, 
if amputation is not required, or is impracticable, the 
surface after removal of the slough must be dressed on 
antiseptic principles. 

Dermatitis from the ingestion of certain drugs is 
rather more frequent than is generally supposed. A 
considerable number of medicines in daily use produce 
in some persons inflammatory eruptions which are often 
puzzling to the physician as well as annoying to the 
patient. 

With regard to most of these drugs, only a compara- 
tively small proportion of individuals who take them 

4* 



82 Diseases of the Skin. 

are attacked. The reason for the susceptibility on the 
one hand and the immunity on the other is not known. 

The following is a brief abstract of the cutaneous 
manifestations which have been noted after the adminis- 
tration of the drugs mentioned : — 

Erythematous eruptions have been noticed after 
taking belladonna, hyoscyamus, stramonium, nitrite of 
amyl, chloroform, arsenic, quinine, opium, turpentine, 
cubebs, copaiba, antipyrin, and benzoate of sodium. 

Urticaria has been observed after taking copaiba, 
quinine, opium, chloral hydrate, carbolic acid, arsenic, 
bromide of potassium, salicylic acid, and antipyrin. 

The urticarial and erythematous eruptions are fre- 
quently combined in the same case. 

Polymorphous erythema has occurred after arsenic, 
quinine, digitalis, copaiba, and bromide of potassium. 

Vesicular and bullous eruptions sometimes follow the 
administration of arsenic (herpes zoster), cannabis 
Indica, iodide and bromide of potassium, quinine, sali- 
cylate of sodium, phosphoric acid. 

Pustular and phlegmonous eruptions (pustules, boils, 
abscesses, diffuse phlegmons, erysipelatous inflamma- 
tion) have been observed after taking iodide and bromide 
of potassium, arsenic, quinine, hyosc} 7 amus, opium, 
chloral hydrate, digitalis, iodide of mercury, calomel, 
and pilocarpine. 

Purpura has been noted after iodide of potassium, 
salicylic acid, quinine, chloral hydrate, and camphor. 

The diagnosis of drug eruptions may cause some 
difficulty. The eruption from quinine sometimes pre- 
sents a very marked resemblance to scarlet fever, at 
others to acute general eczema, and at still others to 
erysipelas. The first and last can generally be excluded 
by the absence of other symptoms, such as the high 



Inflammations of the Skin. 83 

temperature, pro.dromic fever, and sore throat in scarlet 
fever, and the burning pain and fever in erysipelas. The 
searlatiuiform quinine eruption sometimes begins with a 
decided chill, followed by high temperature and other 
symptoms of intense fever. The desquamation may 
present all the features usually considered characteristic 
of scarlet fever. 

The treatment of the drug-eruptions consists in stop- 
ping the administration of the drugs causing them and 
meeting special indications as they arise. 

Gangrenous dermatitis is a rare affection in which 
gangrenous patches appear upon different parts of the 
body, usually symmetrically. The patches are most 
frequent upon the fingers, but may occur on any part 
of the body. In a case observed by the author the 
affection w T as limited to the hands. The disease has 
been described under various names, such as local 
asph} T xia of tissues, symmetrical gangrene, and Ray- 
naud's disease. The causes are unknown. Most of the 
cases heretofore reported were in females, and some 
authorities believe that the sloughs were artificially 
produced. It is a well-known fact that sloughing 
patches have frequently been produced by the appli- 
cation of caustics for the purpose of malingering. 

In some diseases of the central nervous system 
acute bed-sores occur. They are probably results of 
vaso-motor disturbances. In cases where injury to the 
main nerve-trunk of a limb has occurred, gangrenous 
patches are sometimes observed in the area of distribu- 
tion of the injured nerve. Gangrenous dermatitis, lim- 
ited to the point of inoculation, is not rarety observed 
after vaccination, especially w 7 ith animal virus. 

Electricity and stimulant applications are indicated, 
but little good can be promised from these measures. 



84 Diseases of the Skin. 

ERYSIPELAS. 

It is probable that erysipelas is in all cases due to 
the inoculation of a specific virus. There is not suf- 
ficient evidence that it can develop out of a simple 
inflammation without the presence of its specific cause. 
In nearly every case a careful search will discover some 
pre-existing lesion where the inoculation may have 
taken place. 

The face, scalp, and extremities are the most frequent 
seats of ei*3 T sipelas. In young infants a veiy fatal form 
is also liable to begin in the umbilicus. 

The symptoms of erysipelas are : high fever, — the 
temperature frequently reaching 104° to 105° F. (40° 
to 40.5° C), — headache, coated tongue, nausea and 
vomiting, and in severe cases, or in nervous individuals, 
mental disturbance (delirium). 

The skin becomes painful, red, swollen, and shiny. 
If the case is mild these symptoms disappear in a day or 
two, and the normal condition of the skin and the 
general system is re-established. In severer cases the 
fever continues, the inflammatory area extends progres- 
sively, the skin becomes boggy, and vesicles or blebs ap- 
pear upon the inflamed patch. The latter may burst 
and thick crusts form by the drying of the effused fluid. 
Local patches of gangrene may occur. In the face, the 
deformity produced by the swelling is often very great. 
The effusion into the loose connective tissue of the eye- 
lids is often so extensive as to completely close the e}^es. 
The ears become thickened, tense, shin} r , and stand out 
prominently from the sides of the head. All of the 
affected skin is exquisitely sensitive, and the lightest 
touch or movement causes complaints of pain. The 
fever and gastric disturbances continue until the violence 
of the disease has reached its acme, after which the 



Inflammations of the Skin. 85 

symptoms progressively decrease. Unless sloughing 
occurs, the integrity of the skin is restored. At times, 
however, limited areas of solid oedema remain, espe- 
cially about the lips, eyelids, and lower extremities. In 
some cases a predisposition to a return of the disease 
remains, and the patients are compelled to pass through 
an attack three, six, or even twelve times a year. 
Eventually, in many of these latter cases, a condition 
simulating elephantiasis arabum remains. 

Recent researches (Koch, Fehleisen, Orth) indicate 
that the disease is due to a micrococcus, which has been 
isolated by Fehleisen. Pure cultures of this organism 
injected into healthy individuals have produced the 
disease. 

The prognosis of erysipelas depends greatly upon 
the vital resistance of the patient. Persons of good 
habits, temperate, not run down by overwork or fore- 
going disease, and living amidst hygienic surroundings, 
are very likely to recover, even from severe cases. On 
the other hand, persons of depressed vitality, or of 
dissipated habits, especially those addicted to alcoholic 
excesses, frequently succumb to the disease. The eiy- 
sipelas of the newborn is also almost always fatal. 
Erysipelas occurring as a complication of vaccinia is 
often of grave significance, because it is mostl}- an indi- 
cation of a debilitated constitution in the vaccinee. 

The treatment of erysipelas by the internal adminis- 
tration of tincture of chloride of iron is so often fol- 
lowed by marked decrease of the inflammation that I 
cannot doubt the good effects of this remedy. It is my 
practice to give it in half-drachm [2.] doses, well diluted, 
every two or three hours. Irritability of the stomach 
sometimes interferes with this treatment for a time, but 
if the administration of the medicine is persisted in, 



86 Diseases of the Skin. 

and especially if a little dilute phosphoric acid and 
syrup of lemon are added, the stomach soon becomes 
tolerant of it, and it is retained. It is often useful to 
combine quinine with the iron. 

Locally, a simple cold- or hot-water dressing will 
relieve the heat and burning pain. Lotions of bicarbon- 
ate of soda, of acetate of lead and opium, or of carbolic 
acid are also widely used. 

The parenchymatous injection of a 2- to 3-per-cent. 
solution of carbolic acid into the periphery of the in- 
flamed area, as at first recommended by Hiiter, is highly 
thought of by some. Painting the inflamed patch with 
tincture of iodine is also believed to limit the spread of 
the inflammation. Collodion, either alone or holding in 
solution iodoform, has been used with success in the 
same manner. Recently the local application of white- 
lead paint has been highly recommended b}' Dr. Lewis, 
of New York. 

FURUNCLE. 

A boil is an acute, circumscribed inflammation of 
the skin, frequently extending into the subcutaneous 
tissue. It usually begins as a small induration, gradu- 
ally elevating the skin into a conical prominence, tender 
to the touch, and accompanied b} r severe throbbing 
pain. The apex of the cone is the site of a small, yel- 
lowish pustule, and when this is punctured a few drops 
of pus escape. In some cases this terminates the morbid 
process, and the induration gradually disappears. These 
are called " blind boils." In the majority of cases, 
however, the inflammatory area extends to the size of a 
hazel-nut, or even an English walnut. In the course of 
a week the swelling becomes boggy in the centre, the 
summit breaks down, and a yellowish plug of dead con- 
nective tissue, covered with pus, is discharged. When 



Inflammations of the Skin. 87 

all the necrosed tissue has been thrown off the cavity 
fills up by granulation, and a small, irregular scar re- 
mains to mark the site of the boil. 

The causes of boils are, in the majority of cases, 
external irritants. Thus, they frequently occur at the 
back of the neck, where the}^ are often due to friction 
of a stiff, jagged collar. About the wrists they are 
often caused by a frayed shirt-cuff. Between the but- 
tocks, or about the genitals, they are often due to acrid 
discharges or other irritants. They are not rarely ac- 
companiments of pruritic skin diseases, and are then 
caused by the irritation of scratching. 

Boils are often an external evidence of diabetes, 
and when, in any case, large numbers of boils occur 
scattered over the surface, it is well to bear this con- 
nection in mind. 

It is a common saying that boils never come singly, 
but always in crops. This is in large measure due to im- 
proper treatment. The continued application of poul- 
tices, or irritant salves and plasters, is often responsible 
for the persistence of furuncular eruptions. 

The diagnosis presents no difficulties. 

The treatment of boils consists in free incision, fol- 
lowed by warm dressing or a poultice, and the internal 
administration of large doses (n^xx to xxx) [1.3 to 2.] 
of tincture of chloride of iron. Quinine may often be 
added with advantage. A brisk purge may be given at 
the beginning of the treatment if indicated, but the 
persistent administration of laxatives, such as sul- 
phur, cream of tartar, and similar medicines, is to be 
deprecated. 

I have never seen any good effects from the use of 
sulphide of calcium or arsenic in boils, but often the 
reverse. 



88 Diseases of the Skin. 

The incision of the boil should be made as soon as 
the diagnosis is certain. It relieves the congestion and 
throbbing pain, frees the way for the exit of the slough 
and pus, and leaves a fine, linear mark, instead of the 
irregular scar which nearly always remains if the boil 
has been allowed to break. 

The poulticing or hot-water dressing should be con- 
tinued only long enough to permit the engorged vessels 
in the areola of the slough to become depleted. Five 
or six hours is usually long enough. Afterward, the 
incision should be covered with a piece of lint smeared 
with carbolic-acid ointment. 

ANTHRAX. 

Carbuncle may be described as a diffused boil with 
multiple openings. In all essential particulars it is 
identical with the affection last described. The ear- 
buncular swelling is broader, not so elevated as, and 
more firmly indurated than, that of a boil. Its surface 
is irregularly flattened. The necrotic masses are dis- 
charged through a number of openings, which have 
caused the top of a carbuncle to be compared to a sieve. 
There is usuall} 7 severe pain, considerable fever, and 
often great depression of the system. 

The causes are the same as those of furuncle. 

The treatment differs in no respect from that of boils, 
except that it should perhaps be more energetic. In car- 
buncle of the lip, in which the prognosis is usually con- 
sidered so very grave, early incision and the free adminis- 
tration of iron and quinine are imperative. To delay 
incising the swelling until pus is discovered b} r fluctuar 
tion, is merely tampering with the life of the patient. The 
dressing after. incision should be actively antiseptic, in 
order to prevent septic absorption. Lotions of carbolic 



Inflammations of the Skin, 89 

acid (5 per cent.) or of mercuric bichloride (1 to 2000) 
should be kept constantly applied. 

In addition to the administration of iron and quinine 
for their "specific" effect, the patient should have a 
liberal allowance of good food and alcoholic stimulants. 
This is especially important in patients of advanced age, 
who so often succumb to this disease. 

DIFFUSE PHLEGMON. 

Diffuse phlegmonous inflammation of the skin, also 
termed phlegmonous erysipelas, is properly a celluli- 
tis. It is most frequently observed in the forearm and 
the neck. The morbid process consists in a necro- 
sis of connective tissue, accompanied or followed by 
lymphangitis and dermatitis. The origin of the affec- 
tion is probably always septic. 

The disease begins with a chill, followed by fever. 
The patient sometimes has recurret attacks of chilliness, 
or regular periodic rigors. The affected locality be- 
comes painful, hard, and swollen. In a few days the in- 
duration gives place to a boggy fluctuation. In some 
cases resolution may take place even at this time, but 
generally the connective tissue breaks down and is con- 
verted into an ichorous pus, in which numerous frag- 
ments of broken-down connective tissue are found. 

If the affected surface is extensive the strength of 
the patient rapidly becomes exhausted, or symptoms of 
septic absorption come on. When the neck is the part 
involved, there is deep destruction of tissue, and the 
pus frequently gravitates into the mediastinum. In 
fatal cases, nephritis is an almost invariable com- 
plication. 

The treatment must be conducted on surgical prin- 
ciples. Deep and extensive incisions, to afford free 

D 3 



90 Diseases of the Skin. 

exit to the necrosed tissue, and antiseptic dressings 
constitute the local measures. Internally, iron, quinine, 
and alcoholic stimulants are indicated in all cases. 

MALIGNANT PUSTULE. 

This is a localized gangrene due to the inoculation 
of the virus of splenic fever (bacillus anthracis). It 
usually appears on the hand, but sometimes also on the 
face. It begins as a red papule or tubercle, accompa- 
nied by itching or burning. A hemorrhagic vesicle 
soon appears on the apex. The base becomes infiltrated 
to the size of a dollar or larger. This often undergoes 
necrosis, and, if the patient escapes general infection, 
leaves a scar after healing. 

Lymphangitis, axillary abscess, and extensive slough- 
ing of the tissues of the arm, chest, or neck are frequent 
complications, and often carry off the patient. The dis- 
ease occurs especially in persons handling the hides of 
animals that have died from splenic fever. It is rarely 
observed in this country . 

Absorption of septic matters sometimes occurs, 
during dissection or post-mortem examination, either 
through an accidental wound or through a slight abra- 
sion. A localized inflammation results, which may 
eventuate in a lymphangitis and general septic infec- 
tion. Oftener, however, a hemorrhagic vesicle or a 
painful tubercle appears, to which Wilks has applied the 
term u verruca necrogenica." 

The treatment consists in cauterizing the point of 
inoculation, and dressing the resulting sore with iodo- 
form. 

It is probable that the ill effects of septic inoculation 
can be prevented by the free use of a disinfectant solu- 
tion of mercuric bichloride (1 to 1000). 



Inflammations of the Skin. 91 

HERPES SIMPLEX. 

Simple herpes is usually divided into two varieties, 
which differ in their localization, as well as, probably, 
in causation. They are herpes of the face and herpes 
of the external genital organs. 

Herpes of the face occurs most frequently on the 
lips, at the angles of the mouth, and upon the nose. 

The eruption generally appears in the course of 
inflammatory or febrile diseases ; hence, called " fever- 
blisters." It has no prognostic significance. 

The eruption occurs in groups of pearly vesicles, 
which either dry up, leaving a thin, brownish scale to 
fall off, terminating the morbid process ; or the vesicles 
are ruptured and a superficial painful erosion remains, 
which, if seated at the labial angle, may remain for a 
long time and cause considerable discomfort. At every 
movement of the mouth — in laughing, talking, or eat- 
ing — the sore spot is disturbed, pain is caused, and 
healing is delayed. 

An eruption of herpetic vesicles also occurs some- 
times, on the mucous .surface of the mouth, and may 
cause much annoyance. 

The treatment is simple. The constant application 
of a mild calomel ointment,, or, if the site of the erup- 
tion is moist, dry calomel dusted on, are all the 
therapeutic measures necessary. The disease tends to 
spontaneous recovery, and will always get well if not 
irritated or injured. 

Herpes of the external genitals is rather a frequent 
affection. It occurs in both sexes, but is most frequent 
in males. It appears in little clusters of clear vesicles, 
situated either upon the cutaneous or mucous surface 
of the prepuce, or upon the glans. The tops of the 
vesicles soon become macerated and rubbed off, and 



92 Diseases of the Skin. 

leave small superficial erosions, which sometimes are 
quite painful. The affection is frequently, recurrent, 
breaking out in some individuals after every sexual 
intercourse ; in others, it only appears after intercourse 
with certain women, indicating that something irritant 
in the vaginal secretions causes the eruption. In other 
cases again, no connection can be traced between the 
outbreak and a foregoing irritation. 

When the affection occurs on the glans or mucous 
surface of the prepuce, or on the mucous surface of the 
labia, the diagnosis between herpes and the initial lesion 
of syphilis is often difficult, and sometimes impossible. 
In these cases a delay of a few days will usually clear 
up the diagnosis. The irrational treatment with strong 
caustics, to which every lesion on the genitals is sub- 
jected by so many physicians, is often the cause of 
uncertainty in making a diagnosis. 

The treatment consists in the application of pow- 
dered calomel, oxide of zinc, or boracic acid. The 
vesicles should be protected from rupture by a pledget 
of lint or absorbent cotton. Where the tops of the 
vesicles have been rubbed off, and the eroded base 
exposed, iodoform dusted on produces rapid healing of 
the sores. Sometimes the tendenc} T to recurrence of the 
affection can be diminished by the regular use of astrin- 
gent lotions containing tannic acid, alum, or sulphate 
of zinc. Cleanliness, of course, is all-important. 

In cases of redundant prepuce, circumcision will 
exert a favorable influence upon the relapsing tendency. 

HERPES ZOSTER. 

Herpes zoster, or " shingles," 1 consists in an eruption 
of groups of large vesicles upon an inflamed patch of 

1 A corruption of the Latin Cingulum, a girdle ; so called because in 
the typical form of the disease it surrounds the body, partly, like a girdle. 



Inflammations of the Skin. 93 

skin, generally limited to one side of the body, follow- 
ing the distribution of the peripheral terminations of 
the sensory branches of nerves, usually preceded by 
slight febrile symptoms, and more or less severe neural- 
gic pain. 

It usually begins as follows : After a few days of 
slight febrile disturbance and neuralgia, sometimes very 
intense, an eruption of small, erythematous spots is 
noticed, in the centre of which there develop small 
papules. In a da} r or two the papules have changed 
into vesicles, which are often umbilicated like small-pox 
vesicles; the contents of the vesicles either dry into thin 
crusts or change into pustules, which sometimes leave 
slight scars, resembling somewhat the pits in small-pox. 
In from two to four weeks the crusts have fallen off, 
leaving the skin in its normal condition, or else the 
scars just referred to may remain to mark the site of the 
eruption. The pain is usually most severe and per- 
sistent in old persons. In children it is sometimes 
entirely absent, merely a slight soreness being felt. 

Shingles is a self-limited disease, and occurs, as a 
rule, but once in a life-time. 

The severe neuralgia may last weeks, months, or 
even years after the disappearance of the disease. 

The cause of shingles is still a matter of discussion. 
The regularity of distribution of the eruption and the 
pain first led von Barensprnng to attribute it to nerve- 
lesions. Rare opportunities for post-mortem exam- 
inations in cases of shingles revealed l^persemia, or 
nflamination of the corresponding cutaneous nerves in 
continuit3 r , or some structural alteration in the ganglia. 
The cause of the disease in the nerves, in some cases, is 
traumatism : thus, zoster sometimes occurs in conse- 
quence of injuries to the cutaneous nerves or ganglia; 



94 Diseases of the Skin. 

but, in the majority of cases, the neuropathy has been 
looked upon as spontaneous. 

Contrary to most dermatologists, the writer believes 
that shingles should be classed with the acute infectious 
diseases. Points in favor of this view are : — 

1. The strictly self-limited character of the disease, 
and its tendenc}^ to spontaneous recovery after a slightly 
varying duration. 

2. The constant occurrence of more or less well- 
marked prodromic s3*mptoms. 

3. The character which it possesses, with the other 
specific diseases, of occurring but once (generalfv) in a 
life-time. 

4. The uselessness of attempts to " cut short " the 
disease b}~ therapeutic measures. 

5. The well-attested quasi epidemic character of its 
prevalence at times. 

Erb, Landouzy, Gerne, and Kaposi have recently 
adopted this view, which was first distinctly proposed 
by myself, in a paper published in the Archives of 
Dermatology for. July, 1877. No other theory so readily 
accounts for the pathogen}^ of herpes zoster. 

Herpes zoster is localized according to the distribu- 
tion of the cutaneous nerves ; thus, in the face, it gener- 
ally follows the distribution of the fifth or seventh, 
which latter receives sensory branches from the fifth. 
When it occurs in the course of the ophthalmic branch 
of the fifth, there are usually intense pain and inflam- 
mation of the eye, which may lead to disorganization of 
that organ. 

Zoster may be conveniently subdivided into facial, 
where the distribution is as just described ; occipital, 
following the ramifications of the third cervical, which 
gives off the occipitalis minor, auricularis magnus, and 



Inflammations of the Skin, 95 

subcutaneous colli. Among the other local forms, the 
cei'vico-subclavicular follows the distribution of branches 
of the fourth cervical, supplying the clavicular and 
subclavicular regions, shoulder, and upper part of the 
back. 

Cervico-brachial follows the distribution of branches 
of the four lower cervical and two upper dorsal nerves, 
and occupies the neck, shoulder, or upper extremity. 

Dor so-pectoral follows the distribution of the third, 
fourth, fifth, sixth, and seventh dorsal (intercostal) 
nerves. Before it breaks out, the malady termed inter- 
costal neuralgia frequently exists for some da}^s. It is 
the most frequent variety of zoster, and from it and the 
following division the name zoster, a belt, 1 is derived. 

Dor so-abdominal zoster follows the distribution of 
the eighth to twelfth dorsal and first lumbar nerves, 
extending in a beautiful zone of vesicles from the spine 
to the linea alba. 

Lumbo-inguinal follows the distribution of the first 
and second lumbar nerves and anastomosing branches, 
being most frequently confined to the inguinal region. 

Lumbo-femoral follows the distribution of the second, 
third, and fourth lumbar nerves, occupying buttock, hip, 
thigh, or leg. 

Sacro-ischiatic and genital occurs upon the penis, 
scrotum, or, in the female, the vulva and the perineum. 

The prognosis in herpes zoster, so far as the eruption 
is concerned, is favorable. The neuralgia accompanying 
it is, however, frequently very persistent. 

The treatment is extremely simple : protecting the 
vesicles from rupture by covering them with cotton- 
batting ; dusting with a powder of starch or chalk con- 
taining morphine or camphor, to relieve pain. For the 
1 See note, p. 92. 



96 Diseases of the Skin. 

same purpose, hypodermatic injections of morphine or 
atropine in the track of the nerve. Large doses of 
quinine have been recommended. Recently, phosphide 
of zinc, T 2 2 to | grain [.005 to .01] three times a day, has 
been used, internally, in the form of a pill, and, it is 
asserted, with success in relieving the pain. 

For the neuralgia, which is sometimes so persistent 
after the eruption has disappeared, arsenic, belladonna, 
or, locally, electricity may be used. In patients with 
broken-down health, the measures appropriate in such 
cases — good food, fresh air, exercise, iron and quinine — 
should be directed. The regular and proper use of the 
constant current promises most success in relieving the 
pain. 

DERMATITIS HERPETIFORMIS. 

This is a rare disease which has been described by 
several authors, but most thoroughly studied by Duhring, 
from whose writings on the subject the following ac- 
count is condensed. The disease may appear in various 
types, — erythematous, papular, vesicular, bullous, pus- 
tular, or a combination of all of these. 

In severe cases prodromata are usually present for 
several days preceding the cutaneous outbreak, consist- 
ing of malaise, constipation, febrile disturbance, chilli- 
ness, heat, or alternate hot and cold sensations. Itch- 
ing is also generally present for several days before any 
sign of efflorescence. Even in mild cases slight sys- 
temic disorder may precede or exist with the outbreak. 
This latter may be gradual or sudden in its advent 
and development. Not infrequently it is sudden, one or 
another manifestation breaking out over the greater 
part of the general surface diffusely or in patches in the 
course of a few days, accompanied by severe itching or 
burning. 



Inflammations of the Skin. 97 

A single variety, as, for example, the erythematous 
or the vesicular, may appear, or several forms of lesions 
ma} r exist simultaneously, constituting what may very 
properly be designated the multiform variety. The 
tendency is, in almost every instance, to multiformity. 
There is, moreover, in almost every case a distinct dis- 
position for one variety, sooner or later, to pass into 
some other variety ; thus, for the vesicular or pustular 
to become bullous, or vice versa. This change of type 
may take place during the course of one attack or on 
the occasion of a relapse ; or, as is often the case, it may 
not show itself until months or 3 r ears afterward. Not 
only multiformity of lesion, but irregularity in the 
order of development, is the rule, whether during an 
attack or later in the course of the disease. 

Itching, burning, or pricking sensations almost 
alwa}'S exist. When the eruption is profuse they are 
intense, and cause the greatest suffering;. As in the 
case of eczema, before and with each outbreak, they 
become most violent, abating in a measure only with the 
laceration or rupture of the lesions. 

The disease is rare, but is of more frequent occur- 
rence than formerly supposed. The natural history of 
the disease is interesting. The process is in almost all 
instances chronic, and is characterized by more or less 
distinctly-marked exacerbations or relapses, occurring 
at intervals of weeks or months. This disposition to 
appear in successive crops, sometimes slight, at other 
times severe, is peculiar. Relapses are the rule, the dis- 
ease in most cases extending over years, pursuing an 
obstinate, em'phatically chronic course. All regions are 
liable to invasion, including both flexor and extensor 
surfaces, the face and scalp, elbows and knees, and palms 
and soles. Excoriations and pigmentation, diffuse and 

5 E 



98 Diseases of the Skin. 

in localized areas, are in old cases always at hand in 
a marked degree. The pigmentation is usually of 
a mottled, dirty, yellowish or brownish hue, and is 
persistent. 

The treatment is symptomatic. The itching gen- 
erally requires measures for its relief. Locally, the 
preparations of sulphur and tar may be used with good 
effect. Internally, arsenic in small doses, combined 
with iron and quinine, sometimes seems to be useful. 

PSORIASIS. 

Psoriasis is a chronic disease of the skin, character- 
ized by the excessive formation of pearly-white scales 
seated upon a reddened, somewhat elevated base. On 
detaching the scales with the finger-nail, the denuded 
spot bleeds slightly. 

The disease begins with punctiform, reddish spots, 
the tops of which become covered in a day or two with 
minute collections of white scales. These efflorescences 
are alwaj'S multiple. They increase peripherally, and 
soon attain the size of a split pea, or lentil, when they 
look very much as if drops of mortar had been spat- 
tered upon the skin. The peripheral increase continues, 
so that the individual lesions become disks of the size 
of various coins. The individual patches may now run 
together, forming irregular-figured patches of various 
sizes. 

The development of new points of efflorescence 
continues, so that in a case of some duration all the 
different-sized lesions may be present. 

When involution of the patches occitrs, the scales 
disappear from the centre, leaving a slightly elevated, 
more or less red or grayish, pigmented spot, while the 
scale-covered border may continue extending periph- 



Inflammations of the Skin. 99 

erally. The pigmentation finally disappears, leaving no 
scar to mark the site of the eruption. 

The only subjective symptom attending an outbreak 
of psoriasis is itching, which is seldom very intense. 
In rare cases it is, however, exceptionally severe. It is 
most marked in the beginning of the disease. 

The anatomical changes consist principally of an 
enormous hyperplasia of the Malpighian layer of the 
epidermis, with secondary hyperemia and exudation in 
the corium, especially the papillary layer. The epithe- 
lial hypertrophy may extend downward, invading the 
cutis, and in very exceptional instances (White) lead to 
cancerous degeneration of the affected skin. 

The eruption is usually symmetrical, and no portion 
of the skin is exempt ; but it is especially localized on 
the extensor surfaces of the limbs and trunk, over the 
sacrum, and upon the haiiy scalp. The palms of the 
hands and soles of the feet are only very rarely affected. 
In nearly all cases the elbows and knees are the seats 
of large, thick patches. 

Upon the scalp the accumulation of scales is often 
enormous, a thick crust being formed, which covers the 
entire head. There is usually a hypersemic band ex- 
tending crown-like around the head, be}^ond the hairy 
border. When it affects the ears it may produce func- 
tional deafness, by causing an accumulation of scales 
in the auditory meatus. 

The nails are sometimes attacked, becoming dry, 
brittle, roughened, and lustreless. 

Bearing the principal features of psoriasis in mind, 
the diagnosis in most cases should not be difficult. In 
some instances, however, no little difficulty arises in 
differentiating it from diseases presenting like ap- 
pearances. 



100 Diseases of the Skin. 

Sebarrhcea of the scalp often presents a condition 
very similar, at first glance, to psoriasis. In the 
former, however, the scales are greasy and dirty-look- 
ing, and there is often falling out of the hair. The 
abrupt-curved border is also wanting in seborrhcea, in 
which the redness is generally less marked, and shades 
off insensibly into the normal skin. 

Scaly eczema may sometimes resemble psoriasis so 
nearly as to make an exact diagnosis impracticable for 
some time. By carefully watching the progress of the 
disease, however, the differentiation can usually be 
made. In eczema there will often be moist patches 
interspersed among the scaly spots, and there will be 
yellowish crusts and scabs in addition to the scaliness. 
In psoriasis, exudation of fluid upon the surface and 
crusts are absent. The well-defined outline is also want- 
ing in eczema. 

The squamous syphilids may sometimes be mistaken 
for psoriasis. The eruption in syphilis is generally 
more copiously distributed on the flexor than on the 
extensor surfaces, and is especially liable to occur in 
the palms of the hands. On scraping off the scales in 
the syphilitic eruption there is no bleeding. The red 
color in psoriasis is due to hyperemia of the cutis, and 
disappears under pressure. In syphilis it is due to an 
infiltration, is not so bright-colored, and does not dis- 
appear under the finger. In scaly syphilis there are 
nearly always scaly patches in the palms of the hands. 
In psoriasis the palms are very rarely affected. 

Ringworm of the scalp sometimes resembles patches 
of psoriasis very closely. In ringworm, however, the 
hairs are nearly always affected, being dry and broken. 
The bright-red base of the psoriasis lesions is also want- 
ing in ringworm. 



Inflammations of the Skin, 101 

The prognosis is favorable so far as any individual 
attack is concerned. But in psoriasis there is always a 
peculiar predisposition of the skin, which we cannot, 
with our present knowledge, eradicate. Hence, it is 
the rule for psoriasis to recur at a variable interval. 
For this reason we can never promise any patient a 
cure in the strict sense of the term. 

The treatment of psoriasis must be both constitu- 
tional and local. Among the internal remedies the first 
place belongs to arsenic. For details of administration 
of this remedy, see section on treatment of eczema, 
pages 56 and 57. 

From considerable personal experience I am firmly 
convinced of the great value of arsenic when properly 
administered. Its unquestionable specific action in 
modifying the epithelial tissues renders it an especially 
appropriate remedy in psoriasis, and, in fact, all chronic 
seal}' skin diseases. In some cases of psoriasis it will pro- 
duce a complete disappearance of the eruption without 
any local measures whatever. It must be confessed, 
however, that local treatment alone is competent in 
man} 7 cases to remove the lesions, especially if the out- 
break is not very extensive. 

I believe I have seen good effects follow the admin- 
istration of alkaline diuretics, either as the only internal 
treatment or as a precedent to a course of arsenic. 
The preparation preferred is the acetate of potassium, 
which I usually order in combination with fluid extract 
of taraxacum, as in Formula 41. 

Carbolic acid, 4 to 5 grains (.25 to .30), three times 
a day, made into pills, with powdered licorice, has 
been recommended, but the benefit derived from it is 
very slight. 

The local measures of treatment may be divided 



102 Diseases of the Skin. 

into the preparatory and curative. To the former 
belong water (baths, lotions) and soap, while in the 
latter category are included tar, sulphur, naphthol, mer- 
curial preparations, chrysarobin, pyrogallic and salicylic 
acids. 

Baths and lotions, either of pure water or rendered 
alkaline with carbonate of soda, are useful in removing 
the accumulated scales or patches of psoriasis. Their 
employment should be combined with soap and friction, 
in order to free the surface of scales and allow the 
remedial application to be made directly to the dis- 
eased skin. The frictions with soap and water should 
always precede the application of whatever medicament 
is used. 

Tar has always enjoyed a high reputation as an 
external remedy in psoriasis. It is employed either 
pure or in ointment, or alcoholic solution. 

Dr. Bulkley has introduced an alkaline solution of 
tar, which is soluble in water, and which is frequently 
of great value in the treatment of psoriasis. It is pre- 
pared according to Formula 42. 

This may be applied to indurated patches in full 
strength, as above, or diluted with an equal part of 
water. It should always be followed by some sooth- 
ing ointment, such as oxide of zinc or calomel ointment. 

As a substitute for tar, naphthol has been used 
by Kaposi and others. It may be employed in oint- 
ment (5ss-j to §j) [1^8 to 1-16] or in alcoholic 
solution (3j to §j) [1 to 8], Its advantages over tar 
are that it has no decided odor, and does not discolor 
the skin or clothing. At the same time it appears to 
be much less efficient than tar. 

Sulphur is a remedy of value in psoriasis. It is 
sometimes, employed, with good effect, in the form of 



Inflammations of the Skin. 103 

the solution of sulphuret of lime, known as Vleminckx's 
solution (Formula 43). 

The patches are rubbed with this until slight bleed- 
ing results, when the solution is washed off with water 
and a soothing ointment applied for several days, until 
the irritation has subsided. If the infiltration has not 
disappeared, the same procedure may be repeated. This 
method of treatment, although very effectual, is painful, 
and should not be applied over large surfaces at a time. 
It is only required in old cases, where the infiltration is 
deep and extensive. 

One of the most efficient applications is chrysarobin. 
It may be ordered in ointment (9j-3j to 3j) [1-24 to 
1-8], or, better, in collodion or solution of gutta-percha 
in chloroform, which is painted on the patches daily, or 
every other da}\ The strength of this paint may be 
varied from 5 to 20 per cent. It has the advantage 
over ointments of being dry, cleanly, and immovable. 

A caution must be added against using a strong 
application of chrysarobin about the head and face. It 
stains the skin and hair of a reddish brown, and not 
infrequently causes an erysipelatoid inflammation in 
the vicinity of its application. It also indelibly stains 
linen. 

Pyrogallic acid, applied in the same manner as 
chrysarobin, is also often effectual in psoriasis. It 
stains the skin brown or black, and, if applied over a 
large surface at a time, m&y cause symptoms of poison- 
ing (strangury, dark-colored urine, etc.). 

Salic3 T lic acid in solution in collodion (10 to 20 per 
cent.) is useful at times, especially in mild cases. 

For psoriasis about the face and scalp I have always 
used, with good effect, the ointment of ammoniated 
mercury (5ij to §j) [1 to 4]. In the milder degrees of 



104 Diseases of the Skin. 

psoriasis it nearly always produces a rapid disappear- 
ance of the lesions. It should not be applied over too 
large a surface of the skin at a time, as it may be 
absorbed and cause symptoms of mercurial poisoning. 

The treatment of psoriasis is often unsatisfactory, 
and when, after long and earnest endeavor, the patient 
has been freed from his disease, a renewed outbreak of 
the eruption usually appears in the course of a few 
months, or a 3 r ear or two. A permanent cure can never 
be safely promised. 

EXFOLIATIVE DERMATITIS. 

I venture to class under this title several affections 
differing in their clinical features, but having as a com- 
mon symptom superficial inflammation of the skin, with 
furfuraceous or laminar desquamation of the epidermis. 
Exfoliative dermatitis ma}' be acute or chronic, general 
or local. 

I. ACUTE EXFOLIATIVE DERMATITIS OF INFANTS. 

In text-books on skin diseases may be found accounts 
of a fatal affection, which is described under the name 
of "Acute Pemphigus." The disease attacks young 
children only, runs a rapid course, and is, in the ma- 
jority of cases, terminated by death. Hebra and most 
dermatologists of his school emphatically deny the 
occurrence of pemphigus in an acute or epidemic form. 

A r on Hitter has described the disease under the title 
at the head of this article. He observed two hundred 
and ninety-seven cases in the course of ten years. The 
mortality was about 50 per cent. 

The children attacked were nearly all between two 
and five weeks old. There is usually a prodromal stage, 
manifested by abnormal dryness of the integument with 
desquamation of the epidermis, in the form of fine, 



Inflammations of the Skin. 105 

branny scales. The skin of the lower part of the face, 
especially about the angles of the month, becomes red 
and slightly tumid. The margin of the redness, which 
rapidly spreads, is indistinct, not being sharply defined 
against the healthy skin. At the same time, the skin at 
the angles of the month becomes fissured and covered 
with scabs. The mucous membrane lining the pharynx 
and buccal cavity is reddened, and the palatal arch is 
the seat" of superficial erosions, covered by a grayish- 
white exudation. 

The appetite and digestion of the infant remain 
unimpaired, and there is no increase of temperature. 
The redness and thickening of the skin extend over the 
entire bod}". The face becomes covered by yellowish, 
translucent scabs upon a reddened base, intersected 
in various directions by fissures. The skin becomes 
wrinkled, and the upper layer separates from the cutis. 
The epidermis ina} r be detached in large flakes or is cast 
off spontaneously. This process, continuing until the 
entire surface is denuded of epidermis, presents an 
appearance similar to that following an extensive scald- 
ing. In favorable cases the dark, raw-flesh color of the 
cutis soon gives way to a lighter red, and in some cases 
the normal color of the skin is restored in twenty-four 
to thirt} T -six hours. In unfavorable cases, on the other 
hand, the color is a dirty, brownish red, and the cutis 
becomes dry and parchment-like. In those cases which 
terminate in recovery the normal condition is entirely 
re-established in a week or ten da}^s, the skin for a few 
days being covered by a fine, branny desquamation. 

As sequelae of the disease, eczemas of considerable 
extent, or pea-sized and larger, superficial boils and ab- 
scesses, sometimes in large numbers, occur and delay 
complete recovery. At other times extensive phlegmon- 

5* 



106 Diseases of the Skin. 

ous infiltrations occupy considerable tracts of skin, and 
may result in gangrenous destruction of tissue and 
death. In the latter conditions, pneumonia and col- 
liquative diarrhoea not rarely precede the fatal termina- 
tion. 

Relapses are infrequent. When they occur, the 
disease is of a milder t}< pe than originally. 

The disease seems to be a manifestation of septi- 
cemic infection, principally localized upon the external 
integument. 

The diagnosis is easy, no other disease being liable 
to be mistaken for it. In erysipelas, which sometimes 
affects infants in a similar manner, there is always con- 
siderable elevation of temperature ; this symptom is 
absent in exfoliative dermatitis. In pemphigus there 
are blebs surrounded by a reddish border, separated 
from adjoining blebs by healthy integument. In ex- 
foliative dermatitis the redness and thickening are 
progressive and occupy finally the entire surface. 

The post-mortem appearances present nothing char- 
acteristic. The etiology is unknown. The disease is not 
contagious. There are no known means of prevention. 

The treatment is purely symptomatic. Sufficient 
nourishment of the infant at the breast is of the first 
importance. Pure air, the room not kept too warm. 
Locally, cool baths, drying the skin with fine, soft 
cloths, and carefully avoiding friction will meet the in- 
dications in most cases. Ragged and loose patches of 
epidermis should be clipped off with the scissors, and all 
denuded and fissured surfaces dusted with finety-pow- 
dered calomel. The crusts which accumulate at the 
angles of the mouth and render nursing difficult and 
painful, are best gotten rid of by soaking them with oil 
of sweet almonds and carefully removing the loose 



Inflammations of the Skin. 101 

ones by means of a dressing-forceps. Baths of oak- 
bark (80 to 100 grammes to 1 litre of water), one-half of 
this decoction to be added to each bath, are sometimes 
useful. In uncomplicated cases no internal medication 
is necessaiy. All complications, of course, should 
receive appropriate treatment. 

II. BULLOUS EXFOLIATIVE DERMATITIS. 

In another form of exfoliative dermatitis, the epider- 
mis is slightly raised over greater or less areas by collec- 
tions of serous or sero-purulent fluid. This finally dries 
up, or escapes through ruptures in the epidermis, and 
the latter is detached in papery flakes. The surface of 
the skin under the exfoliating epidermis resembles that 
already described (p. 106). This form of the disease is 
generally described in dermatological works as pemphi- 
gus foliaceus. It is sometimes acute, but more fre- 
quently chronic. It is usually a disease of early life, 
although occasionally observed in adults. 

The prognosis in this disease is usually grave. The 
strength gradually gives wajr, and the patient dies under 
all the manifestations of exhaustion. 

The treatment must be guided by the condition of the 
patient. The exposed skin must be protected by some 
bland, fatty application. A paste of finely-powdered 
starch and vaseline, equal parts, may be freely applied. 
Internally, roborant remedies — iron and codliver-oil — 
will be indicated. Arsenic in small doses may be tried. 
Inunctions of codliver-oil will be useful. 

III. CHRONIC GENERAL EXFOLIATIVE DERMATITIS. 

This is a rare disease, first accurately defined by 
Hebra, who named it pityriasis rubra. There is deep- 
red discoloration of the skin, little infiltration, no ex- 
udation on the surface, and absence of papules, vesicles, 



108 Diseases of the Skin. 

or fissures. The epidermis is constantly exfoliated from 
the entire surface, in large, papery scales. The subject- 
ive symptoms are slight, the itching being usually very 
moderate. In course of time (months or years) the 
skin becomes dry, harsh, loses its elasticity and pli- 
ability, the hairs fall out, and the nails become cracked 
and deformed. The patients generally die of progressive 
exhaustion or succumb to some intercurrent disease. 

The administration of quinine sometimes causes an 
acute, general, scaly eruption, resembling somewhat 
exfoliative dermatitis. 

The prognosis is grave. Few patients recover from 
the disease. 

The diagnosis from general eczema is not difficult. 
In eczema there are always moist patches ; there is 
usuallj r infiltration, and the entire surface of the skin is 
rarely attacked. In general exfoliative dermatitis, there 
is sometimes not the smallest patch of healthy skin 
remaining. No other disease is likely to be mistaken 
for it. 

No treatment has hitherto been found of any value. 
Inunctions of almond and raw linseed- or codliver-oil 
promise best results. Internally, iron and good food 
are indicated to counteract the tendency to exhaustion. 

IV. LOCAL EXFOLIATIVE DERMATITIS. 

This disease has been described as a pityriasis (fur- 
furaceous desquamation), occurring in small, round 
spots and larger ci re in ate patches. The color of the 
lesions is a pinkish or rose tint, and the spots are cov- 
ered with fine, white scales. There is sometimes slight 
itching, but no other subjective symptoms. The patches 
are not infiltrated. The chest and neck appear to be 
the sites of predilection, but in one case observed by the 



Inflammations of the Skin. 109 

writer the face was especially affected. According to 
Duhriiig, the disease usually lasts from four to six 
weeks. The general appearance and course of the affec- 
tion recalls the vegetable parasitic skin diseases, but no 
characteristic fungus has yet been discovered. 

The treatment consists in the application of mild 
ointments, such as calomel (5ss to §j) [1 to 16], or yel- 
low oxide of mercury (gr. x to lj) [1 to 50], or salicylic 
acid fgr. v to §j) [1 to 100]. Internally, no treatment 
is required. 

LICHEN. 

Lichen occurs in the form of flat or acuminated, red 
papules, seated upon normally colored skin. The erup- 
tion may be discrete or aggregated. Two varieties are 
described : the plane {lichen planus) and the acuminated 
{lichen ruber acuminatus). The disease is rare, — about 
one case being observed in five hundred cases of skin 
diseases of all kinds. 

The plane variety appears as crimson, flattened, or 
even slightly umbilicated papules, angular in outline, 
usually discrete, though sometimes aggregated in disk- 
shaped groups. The localities in which it is oftenest 
found are the flexor surfaces of the forearm, the calves 
of the legs, the thighs, the penis, and scattered about 
the trunk. The acuminate variety consists of pin-head- 
sized, conical, firm papules, capped with a hard, dry 
mass of epidermic scales, which convey a rough sensa- 
tion to the hands when passed over the affected surface. 
In the most aggravated form these papules become 
closely crowded together, until they present an almost 
uniform red sheet of eruption. This is, however, ex- 
ceedingly rare in this country. Dr. R. W. Taylor has 
shown that the two forms here described are essentially 
different diseases. 



110 Diseases of the Skin. . 

When the eruption disappears, either spontaneously 
or as the result of treatment, a dark, slaty pigmentation 
remains for some time. 

There are, generally, no marked subjective S3'mp^ 
toms. Itching is sometimes present, however, and may 
be a prominent sjnnptom. 

The disease differs from papular eczema in always 
preserving the papular form, which is the only lesion 
present. 

In eczema there are nearly always some of the other 
manifestations of the disease. The itching is usually 
less intense in lichen. 

The dark, slaty pigmentation is also characteristic. 
In psoriasis the pigmentation is usually less persistent. 
The flattened or umbilicated summits of the plane va- 
riety are so characteristic that little difficulty can arise 
in the diagnosis. 

In the milder cases the prognosis is fa Adorable. In 
those cases, however, where a large surface is covered by 
the eruption, the patients frequently die from marasmus. 

In the treatment arsenic claims the first place. It 
should be given until the full pli3 T siological effects are 
manifested, when the disease will usually be found to 
yield. Tonic medicines will also be needed in many 
cases. 

The itching, when present, can often be alla3 r ed by 
alkaline baths or lotions containing carbolic acid. In 
the more localized forms of the eruption amnion iated 
mercury ointment is sometimes of benefit. 

Scrofulous lichen is described b} T German authors, 
but has not been observed in the United States. The 
papules are small, pale-red or yellowish, sometimes 
scaly, and do not itch. The internal and external use 
of codliver-oil never fails in curing the disease. 



Inflammations of the Skin. Ill 

PRURIGO. 

Prurigo is an exceedingly rare disease in this 
country. The proportion of prurigo to all cases of 
skin disease reported to the American Dermatological 
Association is about one in ten thousand. The disease 
appears as a papular eruption, generally beginning in 
childhood, attacking by preference the extensor surfaces 
of the limbs, and never the face or palms of the hands. 
The flexor surfaces of the joints also generally remain 
free from the eruption. 

The itching is intense. In no other disease does 
this symptom approach in severity the itching of 
prurigo. 

The disease is differentiated from lichen by the iso- 
lated character of the lesions, and from eczema by the 
absence of exudation upon the surface (unless an arti- 
ficial eczema has been produced by the scratching) and 
the persistence of the papules throughout the duration 
of the disease. The summits of the papules are often 
covered by small brown crusts, the result of excoria- 
tions produced by the finger-nails in scratching. 

The prognosis is gloomy. A permanent cure is not 
to be hoped for, and even temporary relief is difficult 
to secure. 

The treatment must be palliative. Ointments con- 
taining tar and sulphur may be used with good effect. 
Latterly, ointments or lotions of naphthol (5 to 10 per 
cent.) have been found to give relief. Happily, few 
practitioners in the United States are liable to be called 
upon to treat this terrible disease. 

ATONIC PUSTULAR ERUPTIONS. 

Pustular eruptions will usually be found in individu- 
als who are anremie, or in otherwise vitiated health. 



112 Diseases of the Skin. 

Excluding pustular eczema, syphilis, or pyaemia, a cer- 
tain number of cases of pustular eruptions will be met 
with which cannot be definitely ranged under one head- 
ing. In most text-books they are described under the 
titles " impetigo " and " ecthyma," but many modern 
dermatologists discard these terms altogether. These 
eruptions are usually due to local irritations in debili- 
tated subjects. The pustules are from a pin-head to a 
pea, or even a large bean, in size, flat, or slightly 
convex, with inflamed borders. When they are ruptured 
they leave shallow ulcers, with a grayish, unhealthy- 
looking base. The pustules may be disseminated over 
the entire bod}', but are in most cases localized. In 
adults they are most frequently found upon the legs. 
I have noticed them especially in sailors and other 
persons similarly exposed, and who were, in addi- 
tion, overworked and underfed. In many of the 
cases which have come under my notice, a slight 
sponginess of the gums, suggesting a scorbutic tend- 
ency, has been observed. In badly-nourished chil- 
dren the pustules are not seldom seen upon the face 
and hands. 

The treatment of these atonic pustular eruptions and 
their sequelae, the superficial ulcers, is simple and 
promptly effectual. Cleanliness, dry clothing, dry and 
comfortable bed, fresh air, good and sufficient food and 
rest will often produce a cure without any medicine. 
Tonic medication will, however, be advisable generally. 
As a medicine, tincture of chloride of iron, in doses of 
20 to 30 minims three or four times a day, will fulfill 
all the indications. 

Locally, carbolic-acid ointment, or the ointment of 
**xide or oleate of zinc, or carbonate of lead will pro- 
mote healing of the slight ulcerations. 



Inflammations of the Skin, 113 

CONTAGIOUS IMPETIGO. 

This disease was first described by the late Dr. Til- 
bury Fox, in 1862. It generally appears in the form of 
vesico-pustules or blebs, varying in size from a pea to a 
Lima bean. The blebs rise abruptly from a non-inflam- 
matory base, and usually appear as if only partly filled 
with fluid. The fluid, which is at first clear, rapidly 
becomes changed into a thin, milky pus. This is soon 
absorbed, or dries with the roof of the bleb into a thin, 
brownish crust, with turned-up border, lightly adherent 
at the centre, looking as it' "stuck on," as Fox ex- 
pressed it. 

The eruption usually first appears upon the face or 
hands, and, being auto-inoculable, may be transferred to 
other portions of the body. It is very contagious, and 
usually affects all the children of the same family. It 
rarely attacks adults, but may be inoculated upon them, 
as I have shown experimentally. 

When the scabs fall off a brownish surface remains, 
which gradually fades away. The disease runs its 
course in from two to four weeks. The lesions are 
usually discrete, but sometimes a number of the blebs 
run together, forming a larger patch, which may resemble 
eczema ; the latter disease may also be produced by 
scratching or improper treatment. 

In uncomplicated cases the diagnosis is usually easy. 
Contagious impetigo is sometimes mistaken for pemphi- 
gus ; but the peculiar character of the crusts in the 
former* and the chronic nature of the latter disease 
will suffice to distinguish the two affections. 

The disease is spread by contact. It is believed by 
some to be caused by a parasitic growth. Fox seems 
to have regarded it as an infectious disease. Its cause 
is unknown. 

E 9 



114 Diseases of the Skin, 

The treatment consists in cleanliness, removal of the 
crusts, and dressing the surface with oxide of zinc or a 
weak ammoniated mercury ointment (gr. v to §j) [1 to 
100]. If the child is badly nourished, tincture of chlo- 
ride of iron and codliver-oil will be useful. Patients 
with contagious impetigo should be isolated, to prevent 
spreading of the disease. 

PEMPHIGUS. 

Pemphigus is a chronic disease of the skin, charac- 
terized by the outbreak of blebs, varying in size from a 
small bean to a hen's egg, or larger, generally appearing 
in crops, and accompanied by more or less febrile 
disturbance. This definition sufficiently characterizes 
pemphigus, and marks it as a disease standing by itself. 
It is not merely an eruption of blebs, but successive 
crops of these blebs appear. The blebs of pemphigus 
rise abruptly from the sound skin, have no inflammatory 
areola, and are, in most cases, tensely filled with a clear, 
yellowish — sometimes purulent — fluid, or at times con- 
tain blood. 

In a few days the fluid is re-absorbed ; the roof of 
the bleb, with some of its contents, dries into a thin 
scale, which, when removed, leaves a reddened, but 
otherwise apparently healthy, base. If, by means of the 
prick of a needle, or otherwise, the contents of the bleb 
are discharged, the latter collapses and dries up, as in 
the last instance. Unless irritated by mechanical means 
or stimulating applications, pemphigus blebs rarety con- 
tain pus, and no ulceration takes place at their base; 
hence uncomplicated pemphigus leaves no scars. The 
blebs consist of single cavities, not subdivided into com- 
partments, as are the pustules and bullae of small-pox in 
their earlier stages. 



Inflammations of the Skin. 115 

Diagnosis. — The disease probably most frequently 
mistaken for pemphigus is contagious impetigo. There 
can be little doubt that many cases of " acute pemphi- 
gus " in which the patients recover, or epidemics of 
pemphigus, are really cases of contagious impetigo. 1 
The resemblance is sometimes very close, and only a 
careful investigation will disclose the true nature of the 
disease in many instances. If the characteristic marks 
of the two diseases are remembered, however, no 
mistakes should occur. 

In a number of cases of e^sipelas, frost-bite, burns, 
scalds, and the application of cantharides or mezereon, 
bullae appear on the affected part. Here pemphigus can 
always be excluded by the presence of the uniformly 
reddened or inflamed base upon which the blebs appear. 

In the later stages of acquired S3^philis, a bullous 
eruption sometimes appears, which is termed, b} r some 
authors, " syphilitic pemphigus." The name is mislead- 
ing, as the eruption of bullae is the sole point of resem- 
blance. The bullous syphiloderm, as this affection is 
more properly termed, is differentiated from pemphigus 
b}^ an inflammatory areola surrounding the base of the 
bleb, which becomes purulent, the contents drying into 
a greenish-brown scab seated upon an ulcerated base, 
constituting what is called rupia. The bullous syphilo- 
derm is more frequent in children as a manifestation 
of inherited syphilis. 

The early stage of true lepros}^ is frequently accom- 
panied by an eruption of bullae. In this disease, how- 
ever, some lrypersesthesia, followed by anaesthesia of the 
spots occupied by the blebs, generally precedes the erup- 

1 The grave variety of so-called "acute pemphigus" has been de- 
scribed under the title, "Acute Exfoliative Dermatitis of Infants." See 
p. 104. 



116 Diseases of the Skin, 

tions. Other concomitant symptoms of grave involve- 
ment of the constitution will also be present, and enable 
the physician to exclude pemphigus. 

Small-pox may cause a difficult}^ in diagnosis, — a dif- 
ficulty which is, perhaps, more serious than that pre- 
sented by most other diseases, on account of the results 
which may ensue if a case of the former should fail to 
be recognized. In small-pox, however, the blebs always 
contain pus or blood; are not simple cavities, but sub- 
divided into compartments ; are seated upon an inflamed 
base, and followed by ulceration and loss of substance. 
The prodromic symptoms of small-pox can also usually 
be verified in the latter disease; these do not occur in 
pemphigus. 

In rare cases of exudative erythema, large blebs 
sometimes occur as one of the multiform manifestations 
of this disease. The accompanying papules and the 
generally-present patches of diffused red or brownish 
discoloration will serve to distinguish the affection. The 
so-called herpes iris, which has doubtless sometimes 
been mistaken for pemphigus, is now generally regarded 
as merel}^ one of the forms of exudative er\ T thema. 

In some rare cases of urticaria, the summit of the 
wheal is occupied by a bleb, which im'vy simulate the 
bullous eruption of pemphigus. The presence of other 
wheals, the urticarial irritability of the skin, and the in- 
tense itching in nettle-rash will serve to distinguish it 
from pemphigus. 

Dermatitis herpetiformis may- cause some doubt in 
diagnosis, but in this disease the lesions tend to multi- 
formity, while in pemphigus only blebs are observed. 

Charcot has pointed out that a bullous eruption 
sometimes occurs in consequence of nerve-lesions. 
These eruptions may appear consecutively, simulating 



Inflammations of the Skin. lit 

the recurrent eruptions in pemphigus. Scars remain in 
these cases, however, to mark the seat of the blebs, 
which is an exceedingly rare result in pemphigus. In 
the latter disease, also, the eruption would not be so 
strictly limited to the area supplied by an injured nerve. 

Scabies is occasionally accompanied by large bullae. 
The presence of papules, pustules, furrows, and excoria- 
tions, accompanied by severe itching, and the acarus, 
discoverable with a lens, would exclude pemphigus. 

An important, possibly frequent, and certainly rarely- 
recognized cause of bullous eruptions is the ingestion 
of certain medicines. Arsenic, potassium bromide and 
iodide, quinine, copaiba, and phosphoric acid have been 
followed by bullous eruptions more or less resembling 
pemphigus. It should, in all cases of doubt, be ascer- 
tained whether such medicines have been taken, before 
deciding upon the diagnosis. 

It needs to be added that the practitioner must be 
constantly on his guard against being victimized by 
feigned bullous eruptions, i.e., eruptions of blebs caused 
by the designed application of chemical or dynamical 
irritants to portions of the skin with intent to deceive. 
Hysterical women are, of course, the most frequent 
offenders in this respect; but it must not be forgotten 
that men sometimes malinger by feigning various for- 
midable skin eruptions. The methods by which bulhe 
are produced artificially consist in the application of hot 
iron, sinapisms, cantharides, strong acids or alkalies, 
and, perhaps, in some instances, prolonged pressure. 
The possibility of this occurring must be constantly 
borne in mind in order to avoid being discomfited by a 
malicious or dishonest patient. 

The causes of pemphigus are unknown. 

The prognosis is generally favorable. While relapses 



118 Diseases of the Skin. 

are exceedingly liable to occur, individual attacks can 
usually be controlled by proper treatment. When the 
eruption is very extensive, however, the patient may 
succumb to the disease. 

Treatment. — Arsenic appears to be almost a specific 
in pemphigus. The medicine must be given in full closes 
and freely pushed. Fowler's solution may be given, in 
8- to 10-drop doses, three or four times a day. It 
should be given in sherry wine, as it is better borne by 
the stomach than when diluted with water. Quinine is 
also useful. Good food and proper li3 r gienic surround- 
ings are important adjuvants to the treatment. 

Locally, much may be done to increase the comfort 
of the patient. The blebs should be punctured and the 
affected parts may be bathed with a lotion of carbolic 
acid (gr. x to §j) [1 to 50] or black-wash. Various 
dusting-powders may also be used. When itching is 
severe, Bulkley's liquor picis alkalinus diluted with 6 to 
10 parts of water will often give relief. Bran or gelatin 
baths are sometimes useful. 

In some cases, ointments, such as Hebra's or oxide- 
of-zinc ointment or Lassar's paste, applied on cloths, 
give more relief than baths or lotions. 

Exfoliative pemphigus has been described on page 
107, under the title " Bullous Exfoliative Dermatitis." 



HEMORRHAGES. 



Cutaneous haemorrhages are either traumatic or 
S3 r mptomatic. The former are such as result from 
mechanical injuries, or the bites or stings of insects. 
Flea-bites sometimes cause minute extravasations of 
blood in the cutis, which are of importance merely on 
account of the liability of mistaking them for other 
and perhaps graver troubles. The hemorrhagic spots 
are surrounded by an erythematous areola, and are 
generally attended by considerable itching. 

SYMPTOMATIC CUTANEOUS HAEMORRHAGES. 
I. PURPURA. 

Three varieties of purpura are usually described, 
viz., the simple, rheumatic, and hemorrhagic. The first 
and third probably differ merely in degree, while rheu- 
matic purpura seems to be an outward expression of 
the blood change produced by the rheumatic diathesis. 
The cutaneous manifestations differ very slightly. 

Simple purpura generally appears without constitu- 
tional disturbance. The eruption consists of " small, 
distinct, purple specks or patches," varying from a pin- 
head to a split pea in size. They may be disseminated 
over the surface, but are usually most numerous upon 
the lower extremities. There are no subjective symp- 
toms, unless the eruption is accompanied by nettle-rash, 
as sometimes happens. 

The prognosis is quite favorable. No treatment is 
necessary unless the general condition of the patient 
demands it. 

(119) 



120 Diseases of the Skin. 

Rheumatic purpura occurs in small spots, usually 
localized about the knees and ankles, although it may 
be generally disseminated. It is accompanied b} T fever 
and rheumatic pains in the joints. 

The prognosis is really dependent upon the con- 
stitutional condition (rheumatism). Cases have ended 
fatally. 

The treatment is that of articular rheumatism. Sali- 
cylic acid, alkalies, or oil of wintergreen may be given 
in appropriate doses. No local treatment is necessary. 

Hsemorrhagic Purpura. — Hemorrhagic spots and 
patches of various sizes, varying from a pin-head to a 
small coin, appear upon the skin and visible mucous 
membranes. There may be bleeding from the nose and 
conjunctivae, spitting or vomiting of blood, and bloody 
discharges from rectum and bladder. Lassitude, loss 
of appetite, and digestive derangements usually precede 
the eruption for several days or weeks. The haemor- 
rhages from the mucous membranes may be profuse 
and cause grave depression of the vital powers. 

The causes of the disease are not known. In not a 
few cases it has seemed to be connected with the admin- 
istration of quinine. Iodide of potassium may also 
produce a purpuric eruption, as described in a previous 
chapter. The author has seen a purpuric eruption as 
one of the symptoms of poisoning by camphor. 

The prognosis is usually favorable. If uncomplicated 
with any acute, infectious^disease, or hereditary syphilis, 
hsemorrhagic purpura rarely ends in death. 

Treatment. — Ergot, aromatic sulphuric acid, and 
tincture of chloride of iron are the remedies usually 
depended upon in this disease. Quinine, alcoholic 
stimulants, good food, especially fats, and hygienic sur- 
roundings are important adjuncts in the treatment. For 



Haemorrhages. 121 

the haemorrhages from the mucous membranes, cold or 
astringent applications or tampons ma}' be required. 
To promote the absorption of the effused blood in the 
lower extremities, properly applied bandages are often 
useful. Woodbury has found fluid extract of hamamelis 
(5ss-j) [2. to 4.] of benefit. The bleeding from the 
gums can be controlled, in a measure, by the local appli- 
cation of a 4-per-cent. solution of hydrochlorate of 
cocaine. The latter remedy was first used in this con- 
dition by Waugh. Poulet advises nitrate of silver in 
the form of pills, \ grain (.008) three times a day. 

II. SCURVY. 

Although scurvy is principally a disease of the 
general system, it has such marked cutaneous manifes- 
tations as to demand a brief reference here, especially 
with regard to its diagnosis from the affections just 
described. 

The symptoms of scurvy are lassitude, listlessness, 
pains in the limbs, depression of spirits ; the skin 
becomes pale and sallow. Petechial spots appear, 
generally first on the lower extremities. These may 
coalesce and form large, irregular patches. There is a 
puffy condition of the face, especially marked around 
the eyes. The scleral conjunctiva sometimes becomes 
of a deep red color, but this condition is not accompa- 
nied by pain or purulent discharge. The gums become 
spongy and swollen, sometimes to such an extent as to 
project completely beyond the teeth. They bleed upon 
the slightest touch. This condition of the gums is, 
however, not an invariable accompaniment of scurvy, 
as it is held to be by so many authorities. There is 
often great shortness of breath. The skin and deeper 
tissues are infiltrated with blood, and tumors and bruise- 

6 F 



122 Diseases of the Skin. 

like swellings are frequently produced by the slightest 
injuries. The skin is liable to break down upon very 
slight pressure, and result in fungoid ulcers, which are 
often very destructive. 

The diagnosis from hemorrhagic purpura is not dif- 
ficult if the S3 T mptoms of the two diseases be borne in 
mind. The pallor, listlessness, short-windedness, spongy 
condition of the gums, and bloating of the face are 
absent in purpura. 

The treatment of scurvy consists in suppling an 
abundance of fresh meat and fresh vegetables, and 
placing the patient in a dry, well-lighted apartment. 
Fresh lemon-juice is highly useful in the treatment of 
the disease, as well as in its prevention. 

As a preventive of scurvy at sea, two ounces of 
lemon- or lime-juice per week should be allowed to each 
person. When scurvy appears, the supply should be 
unrestricted. Locally, cocaine may be applied for the 
bleeding from the gums, as practiced by Waugh and 
Woodbury in purpura hemorrhagica. 



HYPERTROPHIES OF THE SKIN. 



The lrypertrophies of the skin may be limited to 
either of the histological strata of this organ, or may 
involve more than one. Hypertrophies of the epidermal 
layer, including pigmentary, epithelial, and papillary 
hypertropy, with their combinations, will be first con- 
sidered, and will be followed by the hyperplastic altera- 
tions of the vascular and connective tissues. 

I. Pigmentary Hypertrophies. 

FRECKLES. 

The sun's rays, acting as a stimulant through the 
peripheral-nerve terminations, sometimes cause an over- 
production of pigment in the skin, which is collected in 
small, roundish masses, causing yellowish or brownish 
spots. These spots are called freckles, and they are 
more frequent in persons of blonde complexion. They 
are especially distributed on those portions of the skin 
covered by clothing, and are more noticeable in summer. 
The Germans call them Sommerfiecke (summer spots). 
The discoloration is due, as above stated, to an increase 
in quantity of the normal pigment of the skin. The 
peculiar arrangement of the coloring matter is, doubtless, 
due to some action of the peripheral nervous system 
which is not clearly understood. 

Freckles are generally believed to disappear entirely 
during the winter season. Hebra has shown, however, 
that this is not the case, but that they grow so faint, in 
the absence of strong sunlight, that they are no longer 
noticeable. 

(123) 



124 Diseases of the Skin. 

These little pigmentary blemishes can hardly be 
looked upon as a disease, but, from a cosmetic point of 
view, the}' are undesirable possessions. Hence, many 
persons, especially of the gentler sex, are anxious to get 
rid of them, and frequently apply to the physician for 
treatment. Inasmuch as the overproduction of pigment 
cannot be checked by any means at our command, a 
radical cure cannot be promised. The affection is, how- 
ever, amenable to palliative treatment. A number of 
applications may be used, which will cause a temporary 
disappearance of the spots. Salicylic acid is one of the 
most effectual of these remedies. It is used in alcoholic 
solution or in ointment (Formulae 43, 44). 

During the day a lotion of corrosive sublimate (gr. j 
to §j) [1 to 500] may be applied two or three times. 

These applications will soon produce a slight scaling 
and roughness of the skin, which is easily subdued by 
grycerite of starch. Should the skin become red and 
irritated, the applications must be intermitted until the 
irritation subsides. 

Should a stronger application be needed, Formula 
45, recommended by McCall Anderson, may be tried. 

This will generally be found too irritant, however, 
for a skin that freckles. Glycerin lotion or glycerite 
of starch should be used during the day. 

In slight cases a lotion of borax and chlorate of 
potash (Formula 46) answers the purpose very well. 

CHLOASMA. 

This is a very frequent affection, occurring upon the 
face, especially in women suffering from disorders of 
the generative apparatus. It is rare in men. The 
common name for it is " moth-patches." The affection 
consists of yellowish-brown or brownish patches on 



Hypertrophies of the Skin. 125 

various parts of the face. The forehead, chin, temples, 
and lower portions of the cheeks are principally affected. 
There is neither desquamation nor infiltration, and no 
subjective symptoms of any kind are present. 

The causes are obscure. It is known that the dis- 
coloration appears frequently during pregnancy, to 
disappear after parturition. It is also a frequent ac- 
companiment of uterine and ovarian disorders, and 
often disappears when these troubles are cured. The 
relation of cause and effect is, however, not known. 

Chloasma resembles very closely tinea versicolor, a 
discoloration of the skin due to a vegetable parasite. 
The latter, however, in nearly all cases occurs upon the 
chest, abdomen, arms, and neck, namely, upon those 
portions of the body covered by clothing. It is very 
rarely seen upon the face or hands. Chloasma, on 
the other hand, is almost entirely limited to the face. 
Tinea versicolor is slightly scaly and sometimes itches. 
Neither of these features is present in chloasma. 
Finally, the latter disease occurs nearly altogether in 
females after the age of puberty, and generally in those 
who suffer from some derangement of the generative 
organs. Tinea versicolor is often er seen in males. 

The treatment of chloasma consists in removing the 
uterine or ovarian disease, if any can be found, upon 
which the pigmentation depends, and in promoting the 
casting off of the superficial epidermal layer, so as to 
bring a less pigmented stratum to the surface. For 
this purpose, the applications recommended above, for 
freckles, will be found useful. The ointment or lotion of 
salicylic acid, or a lotion of corrosive sublimate, 2 to 3 
grains to the ounce, may be used. Soft soap, spread 
upon strips of muslin like an ointment and allowed to 
remain upon the pigmented skin for several hours, will 



126 Diseases of the Skin. 

produce a maceration and desquamation of the epider- 
mis, which often leaves the skin of a normal color after 
the redness has disappeared. The discoloration will, 
however, return, unless the use of one of the ointments 
or lotions mentioned is continued. 

The application which will give the most satisfactory 
results is an ointment of subnitrate of bismuth and white 
precipitate (Formula 47). 

This is applied to the discolorations at bed-time, and 
removed in the morning with Hebra's spiritus saponis 
kalinus. 

This ointment I have used in a large number of 
cases with uniform success. Sometimes it is a little too 
active, and produces irritation of the skin. Its use 
must then be intermitted for a few days, or the oint- 
ment made weaker. Some skins can stand a much 
stronger application, however, and I have used as much 
as two drachms of each of the active ingredients to the 
ounce of vaseline. 

The effect becomes manifest in a few days after 
beginning the use of the preparation. There is slight 
scaling and roughness of the skin, showing that a fur- 
furaceous desquamation of the epidermis is going on. 
In the course of ten to fifteen days the skin has become 
much paler, and, if the application be continued, the 
normal tint of the skin can be regained. This can, how- 
ever, only be maintained by the continued use of the 
ointment, unless the disease of the internal organs, upon 
which the discoloration depends, has been removed. 

The pigmentation of the skin from sunburn usually 
soon disappears after the cause has ceased acting. The 
bleaching can be somewhat hastened by a lotion of cor- 
rosive sublimate in emulsion of almonds (gr. j to §ij) 
[1 to 1000]. 



Hypertrophies of the Skin. 127 

Permanent discolorations of the skin are sometimes 
produced by a mustard poultice or blister. Hence, care 
should be taken to avoid making these applications to 
the face, or upper part of the chest in women, as they 
may prove the source of an annoying or humiliating 
disfigurement in the latter. I have seen a number of 
cases in which the chest had become pigmented from 
mustard poultices, thus interfering with the wearing of 
dresses cut decollete. To many women this is not alto- 
gether a trifling matter. 

In these discolorations the use of the salic} T lic-acid 
lotion, already mentioned, will prove useful. The prog- 
nosis must not be too sanguine, however, as the pig- 
mentation is liable to return. 

In certain chronic cachectic conditions, as cancer, 
tuberculosis, malaria, and Addison's disease, there is 
often a local or general pigmentation of the skin. As a 
matter of course, in these cases, there can be no ques- 
tion of treatment of the discoloration. 

Scratching, friction, pressure, or constant irritation 
of the skin may be followed by localized pigmentations. 
Scars, especially those resulting from syphilitic infiltra- 
tions, also often leave dark spots and markings. They 
usually disappear without special treatment. 

II. Hypertrophies of the Epidermal and Papillary 

Layers. 
EPIDERxMAL hypertrophy of old age — keratosis senilis. 
In many elderly white persons, of both sexes, small 
patches of thickened epithelium xire found, variously 
scattered upon the face, trunk, and extremities. These 
plaques are usually in the shape of roundish, or irreg- 
ular, slightly elevated, brownish or blackish collections. 
Sometimes they are dry and hard, or cornified, but 



128 Diseases of the Skin. 

oftener the patch is greasy to the touch, friable, and 
easily scraped off with the finger-nail, leaving a moist 
and- reddened or slightly bleeding base. 

When these epithelial patches are scraped or rubbed 
off, they rapidly re-form, causing the individuals so 
affected much annoyance, and often uneasiness, by their 
persistence. 

Physicians generally regard this as a trifling ail- 
ment, and pay no attention to it; but careful observa- 
tion will show that, not rarely, the constant epithelial 
hyperplasia results in an at}<pical formation, which 
eventuates in malignant ulceration, — true epithelioma. 

I have several times observed the gradual trans- 
formation of these simple epithelial hyperplasias into 
malignant new formations. 

While this condition of the skin is described by 
most recent dermatologists, only Hyde and Anderson 
mention its occasional termination in malignancy. Dr. 
Hardaway, of St. Louis, has also observed the malig- 
nant transformation of keratosis senilis. 1 

I am impelled by the results of my observation to 
call attention to the possible consequences of a neglect 
of this morbid condition, and to urge more careful 
attention to what is generally regarded as a trivial 
affection. Prompt and appropriate treatment is not 
only desirable for its cosmetic effect ; it may often 
save the patient much suffering, and prolong his 
existence. 

The treatment is generally simple. When there is 
as yet no infiltration, the patches should be softened 
with some indifferent ointment, — cold-cream or vase- 
lin, — and then washed with soap and water, to remove 
all the epithelial accumulation. Soft soap, or spiritus 
1 Manual of Skin Diseases. St. Louis, 1890, p. 216. 



Hypertrophies of the Skin, 129 

saponis kalinus, may be needed for this purpose. After- 
ward, an ointment containing sulphur and salicylic acid 
(Formula 48) may be applied nightly, with success in 
most cases. 

Dr. Hardaway informs me that he has had good 
results from the use of Beiersdorf 's salicylated plaster- 
mull. 

If, after six to eight weeks' persistent use of this, 
the epithelial accumulation returns, the patch should be 
lightly cauterized with caustic-potash solution (1 to 2), 
or the therino-cautery, and following this with oxide-of- 
zinc ointment for a few days, when the use of the 
salicylated sulphur ointment is begun again. 

If there is any infiltration, no temporizing is per- 
missible. The patch must be thoroughly cauterized 
with the thermo-cautery, caustic-potash, arsenious, 
nitric, or lactic acids. In some cases I have obtained 
good results from electrolysis. 

EPIDERMAL ACCUMULATIONS AT THE MOUTHS OF THE HAIR- 
FOLLICLES — KERATOSIS PILARIS. 

Individuals with dry, harsh skins, who are, at the 
same time, too sparing in the use of baths, not rarely 
have a papular affection, especially localized about the 
anterior and outer surfaces of the thighs, the knees, 
etc. This sometimes causes considerable itching, and 
red inflammatory papules or pustules not rarely appear 
here and there. On close observation, it will be noticed 
that the papules consist of little epidermal accumula- 
tions around the mouths of the hair-follicles. The 
papules are frequently perforated by the hair. At other 
times the egress of the hair is prevented, and it ma}' be 
seen curled up under the hard, epidermal cap. 

The free use of hot water and soap will usually 

6* 



130 Diseases of the Skin. 

suffice in removing the accumulated epidermis and 
relieving the subjective S3'mptoms. In other cases, 
frictions with vaselin, sweet almond-oil, cold-cream, 
or a mild salicylic-acid ointment may be necessary for 
a cure. 

EPITHELIAL MOLLUSCUM. 

Epithelial molluscum, also called contagious mollus- 
cum, from its supposed contagious nature, is a rather 
uncommon disease in this country. It consists of 
small, globular tubercles, from a pin-head to a pea in 
size, and generally of a glistening, whitish or pinkish 
color. The summit of each tubercle is somewhat de- 
pressed, and a central point marking the opening of a 
sebaceous follicle can usually be made out. The most 
frequent seat of the disease is the face, especially the 
vicinit}^ of the eyelids. Jt is also sometimes seen upon 
the genital organs. When irritated, the growths may 
inflame and ulcerate. 

The tubercles are firm to the touch. Pressure 
applied to the sides can usually force the contents, con- 
sisting of a whitish, semi-fluid mass, through the 
aperture mentioned. 

English authorities generally regard the disease as 
contagious ; the evidence in favor of this is, however, 
insufficient. Inoculation experiments have always 
failed to transmit the disease. It is more frequent in 
children than in adults. The disease is a hyperplasia 
and alteration of the epithelial layer of the skin. Be- 
sides epithelial cells, the mass which is contained in the 
little growths contains roundish or oval bodies called 
" molluscum bodies." They are not peculiar to this dis- 
ease, but are also found in other diseases of the epithelial 
stratum of the skin. These bodies are believed to be 
the result of a hyaline transformation of rete cells. 



Hypertrophies of the Skin. 131 

The treatment is entirely local. Expression of the 
contents of the tubercles is sometimes successful. In- 
cision and cauterization with nitrate of silver may also 
be practiced with success. Kaposi recommends erasion 
with the curette. The electrolytic method will, how- 
ever, succeed best in permanently removing the growths 
without leaving noticeable scars. 

CALLOSITIES. 

Callosities occur upon the palms of the hands and 
the soles of the feet, and, in fact, any part of the skin 
exposed to intermittent pressure. They are thickened, 
cornified patches, generally of a grayish or yellowish 
color, and slightly elevated above the skin. Shoe- 
makers, tailors, and other mechanics, in whose occupa- 
tions a limited part of the surface is exposed to repeated 
pressure, are liable to callosities. The patch consists of 
an increase of epidermis, closely packed and cornified. 

The treatment consists in maceration of the thickened 
epidermis, and, if necessary, removal with the knife or 
solution of caustic potash. The part should be protected, 
to prevent re-formation of the thickened epidermis. 

CORNS. 

Corns occiqry a position, pathologically, between the 
callosity and the wart. A corn is a circumscribed hyper- 
plasia of epithelial tissue, which projects downward, by 
a conical prolongation, into the deeper epidermal laj^ers 
of the skin. The epithelium is hard and cornified, and 
pressure upon the broad, up-turned base causes exquisite 
pain, on account of the impingement of the apex of the 
cone upon the cutaneous nerves. Sometimes the con- 
nective-tissue Lryer of the skin becomes atrophied from 
pressure, and, at others, inflammation and suppuration 
may occur beneath the corn. 



132 .Diseases of the Skin. 

These formations are usually found over the dorsal 
surfaces of the toes, but not rarely upon the soles of the 
feet or between the toes. The latter are called " soft 
corns," and are, if anything, more painful than those on 
the dorsum or plantar surface. They are generally 
caused by ill-fitting, though not necessarily ki tight " 
shoes. An increase of humidity in the atmosphere 
usually intensifies the pain of corns. Hence the com- 
mon observation, that increase of pain in the corns be- 
tokens a coming storm. This may be explained partly 
by the fact that increasing humidity renders the nerves 
more sensitive. Ultimately, the increased sensitiveness 
is probably due to the lower pressure of the atmosphere 
when the humidity is high, permitting an increase of 
blood-pressure in the skin, and thus compressing the 
nerve-terminations. 

The diagnosis of corns will never give rise to any 
difficulty if the parts are inspected. That errors may 
arise, however, is shown by an interesting case related 
by Hebra, which may be quoted here on account of its 
instructiveness. 

'• The patient was a well-developed, stout soap- 
maker, whose occupation required his standing on his 
feet all day long. The man was suddenly attacked with 
severe pains in his feet. Great resolution was required 
to walk at all, which was only possible by the use of 
shoes with felt soles. His occupation was, in conse- 
quence, much interfered with. Inasmuch as he also 
experienced severe darting pains in his feet at night, 
and w r as, besides, w^ell nourished and fond of the pleas- 
ures of the table, his pl^-sician declared the disease to 
be gout, ordered appropriate internal medication and 
baths, but without good result. The patient was then 
sent to Carlsbad, to use the waters. No relief was ob- 



Hypertrophies of the Skin. 133 

tained until hot baths were tried, when his condition 
was somewhat ameliorated. He still had pain on walk- 
ing, but was easy when the feet were in a horizontal 
position. His return from Carlsbad was followed by an 
intensification of his trouble. He was again put upon 
anti-arthritic treatment, consisting of eolchicum, acetate 
of ammonium, etc., and again sent to Carlsbad. No 
good result following after this second year at Carlsbad, 
I was consulted in the case. In accordance with my 
general rule, always to examine the affected part, which 
had been omitted by the patient's medical attendant, I 
examined the diseased feet and discovered in them the 
cause of the pains. On the sole of the foot was a large 
number of corns, from the size of a millet-seed to that 
of a lentil, and closely packed together. Thej- were 
partly convex and parti} 7 concave from mutual pressure, 
which had given rise to the intense pain. The diag- 
nosis, of course, was made, and afterward confirmed by 
examination of some of the specimens. The immediate 
effect of softening remedies and emollient plasters soon 
relieved the patient, and permitted him to return to his 
occupation." l 

The preventive treatment of corns consists in the 
wearing of properly fitting foot-gear. 

The discomforts of corns can be to a great extent 
relieved by protecting them against pressure. For this 
purpose the perforated corn-plasters sold in the drug- 
stores may be used with success. 

Soaking the feet in hot water and afterward picking 
out the little cone of epithelium constituting the corn 
will give relief for a time, but, so long as the cause 
continues, the corn will return. 

The " soft corns " which are found between the toes 

1 Hebra and Kaposi : Haut-Krankheiten. Bd. ii, p. 26. 



134 Diseases of the Skin. 

generally give most trouble. In these cases a little 
wad of absorbent cotton placed between the toes will 
usually relieve the pain. 

Salicylic-acid collodion, painted on the corn every 
night for three or four nights in succession, will gener- 
ally cause the mass to come out of its bed and make a 
permanent cure. This preparation, or one similar to it, 
containing Indian hemp (Formula 49), is sold in the 
drug-stores under the names of u Gezou's Corn-cure," 
u Russian Corn-solvent," " Green Corn-paint," and per- 
haps other designations. It is an efficient and painless 
remedy. 

The evaporation of the ether leaves an impervious 
and immovable covering of collodion over the corn, 
under which the salicylic acid produces its disinte- 
grating effect upon the epidermal accumulation. The 
extract of Indian hemp is onl} T added for the sake of 
its tine green color. 

A considerable experience with this preparation has 
given me a high opinion of its usefulness. Care must 
be taken not to paint it upon the sound skin, otherwise 
it is liable to cause irritation. 

WARTS. 

Warts are outgrowths of the skin composed of h}'per- 
trophied papillae covered by masses of epithelial cells. 
They are of various shapes, — filiform, pedunculated, or 
seated on a broad base. Their surface may be smooth, 
or rough and irregular. Sometimes the surface is 
granular, constituting the so-called " seed-wart." 

These growths are very frequent, especially in 
children and young persons. Their favorite seat is 
upon the fingers, though the filiform and pediculated 
varieties are not rarely found upon the scalp, e}elids, 



Hypertrophies cf the Skin. 135 

and neck. They are not entirely harmless, as they 
sometimes, though seldom, undergo malignant degenera- 
tion. 

Warts are popularlj r believed to be contagions. 
Among country people the urine of the toad is credited 
with the production of these growths. Inoculation 
experiments have failed to demonstrate their conta- 
giousness. 

In one variety of these structures, the pointed con- 
dylomata or gonorrhoea! warts, the causation is evidently 
dependent upon the irritation produced by acrid dis- 
charges. This variety is usually found upon the genital 
organs, and, by the aggregation of a large number of 
papillary prolongations, may produce cauliflower-like 
excrescences. They frequently secrete an offensive 
acrid fluid, which apparently has the property of repro- 
ducing the growths wherever it comes in contact with 
skin. Hence has arisen a wide-spread belief in their 
origin by contagion. This has not been absolutely 
demonstrated, but seems probable. 

The removal of warts is easily accomplished by ex- 
cision, cauterization, or electrolysis. When large and 
situated upon loose, movable skin, they may be picked 
up between the thumb and forefinger of the left hand 
and snipped off with sharp scissors. The wound may 
be dressed with dry lint or some simple ointment. 

Most practitioners use caustics, fuming nitric acid 
being the favorite. Where many warts are cauterized 
at the same time, however, and especially when they 
are seated over joints, as the knuckles, the process is 
not entirely devoid of danger. I have seen a pretty 
serious case of erysipelas with extensive suppuration, 
leaving ugly scars, m a case in which I had destroyed a 
number of warts on the hands of a young girl. I have 



136 Diseases of the Skin. 

likewise seen a deep, painful excavation produced on the 
scalp by the same means. 

One method of destroying warts, which is pretty effi- 
cient, is to transfix the growth with a needle and then 
heat the end of the instrument in a spirit-lamp. The 
needle gradually becomes hot and produces a slow cau- 
terization. The wart shrivels up and drops off in a few 
days. 

The salicylated collodion recommended for the cure 
of corns is also useful. It will cause a gradual disap- 
pearance of the growth without producing any pain. 
Formula 50 may also be used. 

Recently the internal use of sulphate of magnesia in 
doses of 10 to 20 grains, three times a day, has been 
recommended as a cure for warts. It is said to cause 
their disappearance in two to three weeks. I know 
nothing of its merits from personal experience. 

In my hands, the best results have been obtained 
with electrolysis. The base of the wart is transfixed by 
a fine needle, forming the negative electrode of a galvanic 
battery. From 6 to 20 cells (1 to 4 milliamperes) may 
be used. The circuit is completed b} T an ordinary sponge 
anode held in the hand. In a few minutes the wart 
turns pale, and slight frothing occurs around the needle. 
The circuit is then broken with the anode, and the needle 
withdrawn and passed through the growth at right 
angles to the former puncture and the circuit again 
made. In this way the wart is pierced in various di- 
rections until the base seems to be entirely disorganized. 
In a week or ten days usually the wart drops off, leaving 
a dry, non-cicatricial base. The pain of the operation is 
less than when excision or cauterization is used, and 
there is rarery any scar. When thoroughly done, no 
return of the growth need be feared. 



Hypertrophies of the Skin. 137 

CUTANEOUS HORNS. 

These hyperplastic growths of the epidermis are very 
rare. They often start from altered sebaceous glands, 
but in some cases there is also hypertrophy of the 
papillae. In many cases they seem to be mere out- 
growths from the epithelial layer, their basis resting flat 
upon the skin, and maybe torn off without causing pain, 
bleeding, or other s} 7 mptoms. In those cases where the 
papillae are enlarged, moving the horn will cause pain 
and bleeding. From personal observation of a case, I 
am inclined to believe that this form of horn is especially 
liable to malignant degeneration of its base. From the 
statistics I have examined, I am led to conclude that 10 
per cent, of the cases of cutaneous horns are followed 
by cancer of that portion of the skin where the horn is 
attached. 

These curious structures sometimes grow to a great 
size. Wilson reports one in a Mexican which was four- 
teen inches in circumference around its shaft, and 
divided above that point into three branches. 

The most frequent situations of horns are the head, 
face, and genital organs, although they may be found 
upon any portion of the body. They are more frequent 
in women than in men. 

Cutaneous horns are outgrowths of epithelial tissue. 
If removed the} r show a great tendency to recur, unless 
the base is thoroughly destroyed or excised. The lia- 
bility to cancerous degeneration should be borne in mind. 

The best method of removing these morbid structures 
is, probably, by excision, taking enough of the base and 
surrounding tissue away to remove any chance of recur- 
rence. Cauterization of the base with caustic potash, 
or the thermo-cautery, would doubtless also be efficient, 
if thoroughly done. 



138 Diseases of the Skin. 

The sebaceous glands in the sulcus behind the glans 
penis sometimes secrete a smegma, which becomes corni- 
fied and causes a sort of horny growth, which com- 
pletely covers the glans. These cases are exceedingly 
liable to be followed by epithelioma. The horny mate- 
rial should be softened with oil-dressing or poultices, 
and, if cancerous degeneration has not yet taken place, 
the normal function of the glands may be restored by 
the constant application of a weak sulphur ointment. 
If the organ is already cancerous, of course the only 
procedure indicated is amputation. 

PIGMENTARY N^VUS. 

It is difficult to give an exact anatomical description 
of nsevus. Sometimes the blemish consists merely of 
an excess of pigment, when the spot may be looked 
upon simply as an exceptionally dark freckle. In most 
cases, however, there is, likewise, hypertrophy of the 
entire epithelial and papillary layers, sometimes even 
involving the deeper strata of the corium. Demieville 
has shown that the pigment is mostly accumulated along 
the course of the finer blood-vessels, indicating that the 
coloring matter is derived from the blood. 

Naevi may be flat, or elevated above the surrounding 
normal skin. Their surface is smooth or irregular, and is 
often thickly planted with hairs. They vary in size from 
a pin-head, -or smaller, to large, irregular patches, which 
cover the greater surface of the body. The latter are 
often very hairy, and mixed with fibroid or lipomatous 
growths, as in a remarkable ease illustrated in the vol- 
ume on skin diseases in von Ziemssen's cyclopedia. 

Some observers think that naevi are more frequently 
distributed upon the face than on other regions of the 
body, but this is probably an error. Phj T sicians in 



Hypertrophies of the Skin. 139 

general practice have occasion to see these deformities 
upon the chest, abdomen, and extremities in cases where 
the face is entirely free of them. The greater apparent 
frequency of nsevi upon the face is, doubtless, due to the . 
more favorable opportunities for observation of these 
growths upon a portion of the body constantly exposed 
to view. 

A curious variety of nsevus is that first described by 
Arndt, in 1830, and afterward more thoroughly studied 
by von Barensprung, Theodore Simon, O. Simon, and 
Neumann. In this form the pigmented and papillary 
hypertrophies follow the distribution of one or more 
branches of the cerebro-spinal nerves. Sometimes there 
is also vascular hypertrophy, as in vascular nsevus. 
Barensprung first suggested the dependence of these 
malformations upon disease of the spinal ganglia in 
utero. These cases are not very frequent. 

Naevi are usually considered as mere blemishes, only 
demanding removal when they cause annoyance by their 
size or the disfigurement they produce. But in excep- 
tional cases, especially if subjected to persistent irrita- 
tion, they may undergo malignant degeneration. I have 
seen four cases in which a pigmented mole was the 
starting-point of an epithelioma. One case occurred in 
an elderly maiden-lady, who had attempted the destruc- 
tion of a mole upon the forehead hy the application of 
nitrate of silver. The persistent irritation produced 
resulted in the development of a rodent ulcer, which was 
successfully treated by scraping and thorough cauteriza- 
tion. In another case, a warty mole, situated near the 
tip of the nose, became rapidty cancerous, resulting in 
the formation of a tumor as large as a medium-sized 
pear. Microscopic examination proved the correctness 
of the clinical diagnosis of epithelial cancer. This 



140 Diseases of the Skin. 

tumor was removed by the means of the thermo-cautery. 
In a paper read before the American Dermatological 
Association in 1886, Dr. Sherwell, of Brooklyn, also 
directed attention to the danger of malignant degenera- 
tions. Schwimmer has observed the degeneration of 
moles into melanotic sarcoma. 

The very rare and curious affection described under 
the names of " atrophia cutis," " xeroderma of Hebra," 
and " angioma pigmentosum et atrophicum " may be 
referred to in this place. Dr. R. W. Taylor, of New 
York, has studied the disease most thoroughly in a 
series of cases, and Drs. J. C. White, of Boston, and 
Duhring, of Philadelphia, have added observations of 
their own. There appear to be several varieties or 
stages of the disease. Dermatologists are not yet in 
unison as to the course of the affection, but it seems 
well established that malignant (epitheliomatous) de- 
generation is a frequent termination. The manifesta- 
tions of the disease are somewhat complex. There is, 
according to Dr. Taylor, at first excessive vascular 
development, resulting in the formation of minute, 
bright-red spots, followed by pigmentation and atrophy. 
Dr. White considers the melanotic process to be the 
primary and typical one, and that the atrophj' of the 
skin and vascular development are secondary and non- 
essential. 

The causes of pigmentary naevi are entirely un- 
known. In the majority of cases, they are unquestion- 
ably hereditary. It is probable that in many of the 
cases in which direct heredity cannot be shown, there 
is indirect inheritance. 

In view of the rather frequent malignant degenera- 
tion of pigmented naevi, it is certainly good practice to 
remove them, if situated in a locality subjected to irri- 



Hypertrophies of the Skin. 141 

tation. Every naevus may, without exaggeration, be 
looked upon as a potentially malignant growth. 

The methods of removal are excision, cauterization, 
and electrolysis. When the growth is small, the latter 
method will give the most satisfactory result, as the 
scar which remains is smooth, soft, and non-contractile. 
The thermo-cautery may also be used, but will give 
less satisfaction than electrolysis. 

Acid nitrate of mercurv and nitric acid are the best 
caustics. Their action can be limited, and they leave 
smooth and pliable scars. 

Where the naevus is large and disfiguring, it may 
be excised with the knife, and, if necessary, a plastic 
operation performed to supply the deficiency of skin. 
The operation should be clone as early in life as practi- 
cable, as the growth enlarges with the increase in size 
of the features. 

ICHTHYOSIS — FISH-SKIN DISEASE. 

Ichthyosis is rather rare in this country. The sta- 
tistics of the American Dermatological Association 
show that one case of ichtl^osis occurs in about four 
hundred cases of skin disease of all kinds. 

The name " fish-skin disease " well describes the 
appearance of the affection when well marked. The 
epidermic covering forms variously sized diamond- 
shaped plates, looking very much like the scales of a 
fish. This scaly arrangement is particularly pro- 
nounced upon the lower extremities, and especially 
upon the extensor surfaces. The flexures of the joints 
are usually free from the disease, or affected to a much 
slighter degree. These thickened epithelial plaques 
are generally much discolored, probabl} T owing in part 
to dirt, but partly also to increase of pigment in the 



142 Diseases of the Skin. 

epidermis, as has been determined by microscopic 
examination. 

In the milder degrees of ichthyosis the skin is dry, 
hard, and scal\ T , has a dirty and lifeless appearance, and. 
is totally devoid of the normal softness and pliability, 
except in the flexures of the joints. In many cases 
this stage is not exceeded, the large, thickened, corni- 
fied plates not being produced. These cases are often 
described as xeroderma, or " diy skin." 

In some extreme cases the plates are very much 
thickened, and subdivided by deep clefts into small, 
columnar areas. In others, the epithelial hyperplasia 
seems to be limited to the sebaceous glands, causing 
little spines of hardened epithelium to project from the 
gland-ducts. This form has given rise to one of the 
popular names, " porcupine disease," for these cases. It 
is usualty limited to patches of various size, rarety ex- 
tending over the entire surface of the body. Ordinarily 
the palms of the hands and soles of the feet are exempt 
from this disease, but exceptional^ it may be limited 
to these surfaces. In these cases the diagnosis of tylosis 
is frequently made, but the hereditary nature of ichthy- 
osis and its appearance early in life will enable the two 
conditions to be readily differentiated. 

In very rare instances children are born with an 
ichtli3 T otic skin. These children are generally born pre- 
maturely, and, if living, always die within a few days 
after birth. 

The causes of ichthyosis are entirely unknown. It 
is a hereditary disease, the transmission being usually 
direct, and oftenest in the male line. Instances of cross 
heredity are, however, not infrequent. An interesting 
fact connected with the etiology of ichthyosis is its 
endemic prevalence in certain limited areas of the earth. 



Hypertrophies of the Skin. 143 

Hirsch (" Hist. Geogr. Pathologie," ill, 466) refers to 
reports of such endemics in Borneo, the Molluccas, the 
Marquesas and certain islands of the Samoan group, 
Guayaquil, the Peruvian and Senegambian coasts. The 
prevalence of the disease in these limited areas may be 
accounted for by its pronounced hereditary nature, 
being transmitted and, perhaps, intensified in character 
by the close in-and-in breeding in such localities. Hirsch 
suggests that the disease may be parasitic in origin in 
its endemic form. 

Treatment. — Ichthyosis is not permanently curable 
by any means now known to the profession. The dis- 
ease, however, never produces any unfavorable effects 
upon the general health. The local symptoms may 
always be relieved by appropriate palliative measures. 

Of internal medicines, arsenic and tar have been 
highly recommended by some authorities, but, at the 
present day, few dermatologists use either in this dis- 
ease. From arsenic benefit might reasonably be ex- 
pected, on account of its well-known influence over the 
nutrition of epidermal structures. It has, however, 
failed to realize the anticipations of most of those who 
have given it a trial in this disease. Lombroso has 
used with success, in one case, ustilago maidis, or corn- 
smut, in doses of 30 grains per day, continued, with 
brief intermissions, for four months. 

The first indication in the treatment of ichthyosis is 
to remove the epithelial hypertroph} r , and the second to 
restrict its re-formation as much as possible. 

As the disease is always milder in summer, the 
thought occurs that free perspiration promotes the 
removal of the thickened epidermis, and, on trial, this is 
found to be the case. The administration of jaborandi 
(3j [4.] of the fluid extract daily), or of its alkaloid 



144 Diseases of the Skin. 

pilocarpine (one-fifth grain [.01] hypodermatically), has 
been followed by rapid disappearance of the epidermal 
accumulation. Locally, soft soap, spread upon muslin 
and applied like a plaster, produces rapid maceration 
and removal of the upper layers of the skin, but is liable 
to be followed by eczema, or other forms of dermatitis. 
The soap ma}- also be used in the form of Hebra's 
spirit us saponis Icalinus, applying it, with friction, daily, 
or several times a day, and following its use with some 
soothing ointment, to restrain any eczematous ten- 
dency. 

Alkaline baths, containing from two to eight ounces 
[60. to 250.] of carbonate of soda to the bath, are useful 
in the milder forms. Duhring highly recommends 
vapor-baths. After the skin has been well softened by 
the bath, an ointment should be well rubbed in, with 
considerable friction, constituting a sort of massage 
treatment. Ointments of various composition may be 
used (Formulae 51, 52). 

In my own practice, the simple glycerite of starch, 
so highly recommended by Lailler, has proven very 
effective in mild cases. The addition of 2 to 5 per 
cent, of salicylic acid ought to render this still more 
efficient. 

The wearing of rubber gloves, when the disease is 
localized upon the hands, will keep the skin soft and 
pliable, especially if combined with one of the above- 
mentioned ointments. 

A permanent effect can onty be obtained from any 
of these measures if their employment is persistent. 

HYPERTRICHOSIS — HYPERTROPHY OF HAIR. 

Hypertrichosis is an abnormal condition, manifested 
bj r excessive growth, abnormal distribution, or heter- 



Hypertrophies of the Skin. 145 

ochronism in development of hair. It may be hereditary 
or acquired. In some cases the hirsnteness is general, 
covering, more or less, the entire surface of the body ; 
in others, it is limited to certain circumscribed areas. 

The cases of generalized hirsnties, like those of the 
hairy family of Bnrmah, the Russian dog-faced people, 
Julia Pastrana and her child, and " Krao," are generally 
hereditary.' In the Burmese family the hirsuteness is 
known to have persisted through three generations, 
while in the other instances mentioned two generations 
are known to have been hairy. 

In the minor degrees of hypertrichosis, such as 
ordinarily come under the notice of the physician, the 
hereditary tendency is also marked in the greater 
number of cases. For example, a moustache and beard 
not infrequently u decorate " the female members of a 
family through several generations. In males this is 
often strikingly manifested in the hairiness of chest 
and limbs. 

Hypertrichosis may also be acquired by those not 
hereditarily predisposed. There seems to be some con- 
nection, although it has never been satisfactorily ex- 
plained, between disorder of the genital function and 
overgrowth of hair on the face in women. The facts on 
record bearing upon this problem are, however, too few 
and too indefinite to permit satisfactory conclusions to 
be drawn. 

It has been observed that insane women frequently 
develop hypertrichosis of the face, and some writers 
have concluded that the aberration of mental activity 
bears relation to the hirsnties, but there are reasons to 
believe that in some of these cases the hypertrichosis 
existed before the mental disturbance became apparent. 
Most women are exceedingly sensitive upon the point 

7 G 



146 Diseases of the Skin. 

of their personal appearance, and, as a growth of hair 
upon the face is considered an attribute of masculinity, 
the hairs are assiduously plucked out, or removed at 
frequent intervals with chemical depilatories. When 
mental alienation has become established, less attention 
is paid to personal appearance, and the hairs are per- 
mitted to grow at will. It is not improbable, likewise, 
that the very presence of the hairy growth in a sensitive 
woman may be an exciting cause of insanity. It is, at 
all events, a matter of common observation that most 
women with pronounced beards or moustaches are pre- 
disposed to melancholy. 

Certain neurotic and irritative conditions may cause 
overdevelopment of hair. Possibly the hypertrichosis 
of insane women may be looked upon as a manifestation 
of the neurotic form. Others are seen in some cases 
of hairy naevi, where the pigmentary overgrowths 
evidently occupy the area of distribution of certain 
cutaneous nerves. The patch of hair over the spinal 
defect in spina bifida may also be considered a form of 
neurotic hypertrichosis. 

Surgeons not infrequently observe an overgrowth 
of hair in the vicinity of wounds or ulcers, especially 
if irritating applications have been used. Thus, I have 
seen a pretty free growth of long, dark hair upon a limb 
dressed daily for a long time with carbolized oil. The 
hairs usually fall out, however, after the irritation 
ceases, if the growth is in an abnormal situation. 

A curious relation has been observed to exist between 
the development of the hair and the teeth. In nearly 
all the cases of universal hypertrichosis hitherto re- 
corded, the teeth w r ere defective. A striking exception 
was the case of Julia Pastrana, who, in addition to 
marked hirsuties, had a double set of teeth in each 



Hypertrophies of the Skin. 147 

jaw. A remarkable contradiction to the rule, in cases 
of hairy human beings, is the observation of Darwin 
that hairless dogs have defective teeth. 

Uuna believes that hirsuties is an example of arrested 
development. At first thought this sounds like a para- 
dox, but the theory is a very plausible one, although I 
do not think it accounts for all the facts. It is known 
to embiyologists that the foetus during intra-uterine 
life becomes thickhv covered with hair, which usually 
falls out before birth, and which is often discovered in 
the liquor amnii. Sometimes, however, this ante-natal 
lanugo hair remains until the child is several weeks old. 
According to Unna, the post-natal normal hair-growth 
is of a totally different t} T pe from the ante-natal lanugo. 
In hypertrichosis, however, the normal change of type 
does not take place, and the pre-natal type of growth 
continues. Hence, hypertrichosis may be looked upon 
as an arrest of development, in which the evolution 
from the foetal to the post-natal type of growth has not 
occurred. 

I have elsewhere 1 given my reasons for not accept- 
ing this theory of the distinguished German dermatolo- 
gist. 

The practical ingenuity of an American plrvsician has 
given to the profession a means of permanently removing 
abnormal development of hair. In 1875 Dr. C. E. 
Michel, a prominent ophthalmologist of St. Louis, 
described a method of permanent^ removing ingrowing 
eyelashes b}^ means of the electrolytic current. Dr. 
Hardaway, of the same city, tried the method in hyper- 
trichosis, and w T as able, a few 3-ears afterward, to report 
entire success in removing the hairy overgrowth. 

1 "Studies in Hirsuties," Transactions of the Ninth International 
Medical Congress, vol. v. 



148 Diseases of the Skin. 

During the last eight or nine years the method has 
been largely employed, and always, in competent hands, 
with entire success. I have used it very extensively, 
since 1882, with the greatest satisfaction. The verdict 
of all qualified observers to-day is that the electrolytic 
destruction of superfluous hair is no longer in the 
experimental stage, but a recognized operation, and, 
when properly performed, fulfilling all the claims made 
by its advocates. 

For removing hair by electrolysis the following 
qualifications, instruments, and appliances are neces- 
sary :— 

1. A plentiful stock of patience. 

2. A steady hand. 

3. Good eyesight. 

4. A suitable battery. 

5. Proper electrodes. 

6. A pair of cilia forceps. 

7. A chair w T ith head-rest. 

Without the first three natural qualifications men- 
tioned no one should undertake the treatment of a case 
of hypertrichosis b}^ electrolysis. Defective e3 r esight 
may be aided by suitable glasses, but no substitutes can 
be found for the other two, and a lack of them disquali- 
fies one from properly performing the operation. 

A suitable battery is any one that will furnish an 
even, constant current of moderate intensity. The 
Waite and Bartlett, Fleming or Mcintosh batteries 
(zinc-carbon elements), the Barrett chloride-of-silver 
battery, or the Leclanche cell will answer. I have used 
all of these except the Barrett battery. With the 
latter I have had no experience, but it seems to be an 
excellent instrument for the purpose on account of its 
easy portability. My favorite battery for electrolysis 



Hypertrophies of the Skin. 149 

is the Leclanche. It furnishes a perfectly constant, 
even current, is easily managed, and does not get out of 
order. The only objection to this battery is that it is 
not portable, and can, therefore, only be used at one's 
office. Of this battery I use from six to 
fifteen cells, according to the sensitiveness 
of the skin or condition of the battery, always 
beginning with the smaller number and in- 
creasing the strength of current if necessan^. 
If the battery has a rheostat, this can be used 
for regulating the intensity of the current. 

When one of the zinc-carbon batteries is 
used, from four to six cells furnish a suffi- 
ciently strong current while the fluid is fresh. 
After a time the number of cells may be in- 
creased as necessary. 

A milliamperemeter should always be 
nsed in electrolytic work. In eradicating 
hairs the current-strength may vary from 
one to four milli amperes. 

It should be remembered that the battery 
needed is one that furnishes a constant cur- 
rent. A faradic battery will not answer for 
electrolysis. 

The ordinary sponge-covered disk will 
answer for the positive electrode. For the 
negative a needle-holder and fine needle are 
necessaiy. 

The holder shown in the cut was devised 
by Dr. Hardaway, and is made by the A. M. 
Leslie Compan}% of St. Louis. It is very 
convenient. A fine steel sewing-needle (No. 12) may 
be used, but flexible needles made of an alloy of pla- 
tinum and iridium are preferable. They are thinner 



150 Diseases of the Skin. 

than the finest steel needles, never break, and can be 
bent into ai^ shape desired. 1 

The forceps should have an easy spring, with flat, 
lightly-serrated jaws, and should not have a catch. 

A chair with a firm head-rest must be used. I use an 
ordinary cane-seat arm-chair, with adjustable head-rest, 
and find that it answers the purpose as well as a more 
complicated or expensive oculists' or dentists' chair. 

The steps of the operation are as follow : — 

The patient is placed before a good light — avoiding 
direct sunlight unless modified by frosted glass — and di- 
rected to take hold of the handle of the sponge-electrode, 
the sponge, of course, having been previously moist- 
ened. The operator then sits a little in front of and to 
the right of the patient, and takes the needle-electrode 
in his right hand, holding a pair of tweezers with flat, 
narrow jaws in his left. The needle is then gently in- 
sinuated into a follicle by the side of the hair until the 
bottom of the follicle is reached. This is manifested 
by a slight resistance to the onward passage of the 
needle. The patient is then directed to touch the 
sponge with the other hand, thus closing the circuit. 
The current will immediately pass, and the electrolytic 
action be made manifest by a little frothing around the 
needle. In some skins also a little wheal will be raised 
about the follicle. In from twenty to forty seconds the 
hair can be extracted with the tweezers without the 
slightest resistance or pain. If the hair does not come 
away with perfect ease, the papilla has not been de- 
stined, and the needle should be permitted to remain 
and the current to pass a little longer. The current is 
broken by removing the hand from the sponge-electrode. 

1 The needles are also manufactured by the A. M. Leslie Company, 
of St. Louis. 



Hijpei^trophies of the Skin. 151 

This gives less pain than if the current is closed and 
opened with the needle. 

If the hairs are very close together, they should not 
all be removed at the same time. The hairs should be 
picked out here and there ; otherwise the points of irri- 
tation will be in too close proximity, and, if sufficiently 
intense, may produce small areas of sloughing and leave 
scars. If the operation is properly performed, no visible 
scars should remain. A sitting may last from fifteen 
to thirty minutes. Very few operators can extend it 
beyond the latter time. The sittings may be repeated 
every other day, or, in cases where time is important, 
every day. After the operation, a mild astringent lotion 
may be applied, and the patient should be directed to 
bathe the surface operated upon several times a day, 
with hot water, for five or ten minutes at a time. This 
tends to reduce any hyperemia which may have been 
caused by the operation. 

When the hair-papilla has been thoroughly destroyed 
the hair cannot be regenerated. In most cases, how- 
ever, a number of the hairs return, showing that the 
destruction of the papillae has not been complete. This 
happens in from 5 to 25 per cent, of the hairs removed, 
and depends partly upon the skill of the operator and 
partly upon the direction of the hairs. In some cases, 
the hair-shaft in the skin is so twisted that it is almost 
impossible to strike the papilla. Such hairs often re- 
quire repeated removal before the}^ are finally destroyed. 
The greatest success will usually be obtained on the 
upper lip and chin, while the hairs under the jaw will 
frequently return again and again, to the great disap- 
pointment of both patient and physician. Partial failure 
should not discourage the operator. Persistence will 
surely be rewarded by success. 



152 Diseases of the Skin. 

I may add, that the older the growth of hair the 
more satisfactory will be the result. In young persons 
new hairs continually appear, which sometimes lead the 
patient to think that the operation is unsuccessful, and 
that all the hairs are returning. The fact of the con- 
tinued growth of the hair should be explained to the 
patient before beginning the operation. In older per- 
sons, where the growth is complete, the new crop con- 
sists simply of those hairs which had not been destroyed 
and which grow out again. A second removal is fol- 
lowed by still fewer returns, and, finally, complete success 
is obtained. In younger individuals this period is longer 
deferred, on account of the above-mentioned outgrowth 
of new hairs. 

Where electrolysis cannot be used, the hairs may be 
removed by chemical depilatories. Among those recom- 
mended in the books, Formulae 53, 54, and 55 are least 
likely to produce irritation of the skin. They should 
not be advised, however, unless circumstances demand 
a rapid removalof the hair. Their use is often followed 
by dermatitis or eczema. 

Unfortunately, depilatories are only palliatives, as 
the hair always returns, frequently with more vigorous 
growth ; hence, they must be used constantly (every 
week or two), in order to keep the deformity out of 
sight. After their use, a dusting-powder should be ap- 
plied, to diminish the irritation of the skin. 

III. Hypertrophies of the Connective-Tissue 
Layers. 

scleroderma — hide-bound skin. 
This is a rare disease of the skin, the returns of the 
American Dermatological Association showing a pro- 
portion of about 1 in 4000 cases of skin diseases of all 



Hypertrophies of the Skin. 153 

kinds. It is characterized by a dense, unpliable trans- 
formation of the skin, usually of slow development. 
The surface affected may be limited in extent, or, as in 
cases reported by Schwimmer, involve the entire sur- 
face. 

There are usually no subjective symptoms, except 
such as result from defective mobility or pliability of 
the skin. 

If the sclerotic patch is in the neighborhood of a 
joint, the movements are interfered with. In a case 
reported by Hilton Fagge, in which the disease was 
localized in the face, the movements of the mouth and 
jaws were so much hindered that the patient starved to 
death on account of inability to eat. Sometimes, how- 
ever, there is pain, tingling, or itching. The skin may 
be of a white or yellowish color, but is usually more or 
less pigmented. In one case under my care the skin 
was dry, hard, and of a dull-brown tint. 

Morphcea, which apparently depends upon the same 
pathological conditions as scleroderma, has many clin- 
ical points of difference, and is usually described as a 
separate affection by American dermatologists. In this 
disease there are whitish or mottled, hard, round, oval, 
or elongated plaques, surrounded by a bluish or pinkish 
border. The hard border in morphcea is distinctly 
marked to the touch, while in scleroderma there is no 
distinct line of demarcation between the diseased and 
normal skin. The subjective symptoms of morphcea 
are similar to those of scleroderma. The German 
authors make no distinction between the two affections. 

The pathological process appears to be at first a 
hypertrophy of connective tissue, followed later by an 
atroph}'. In spite of the many histological studies by 
competent observers, the nature of the disease is not 

7* 



154 Diseases of the Skin. 

yet well understood. Schwimmer believes it to be a 
trophoneurosis. Unfortunately, this explanation adds 
little to our knowledge of the affection. 

The etiology is obscure. We only know that it is 
about four times as frequent in women as it is in men. 
Westphal has found morbid changes in the brain and 
Schwimmer peripheral nerve-lesions, in cases examined 
by them. 

The disease sometimes gets well spontaneously, but 
the prognosis is unfavorable. Internal remedies have 
no apparent influence upon the progress of the malady. 
In a case seen by me massage with inunction of cod liver- 
oil and the internal administration of large doses of 
tincture of chloride of iron resulted in a cure. Whether 
the effect is to be ascribed to the treatment is uncertain. 

Galvanism has been used bj r some with asserted 
benefit. In one of Scliwimmer's cases of universal 
scleroderma, galvanization of the sj^mpathetic resulted 
in almost complete recovery after eighteen months' 
continued treatment. 

Alkaline, iron, salt and vapor baths, frictions with 
unguents or oils, the internal use of iron, quinine, or 
other bitter tonics are recommended by various authors. 

SCLEREMA NEONATORUM — INDURATIVE (EDEMA OF THE SKIN 
OF THE NEWBORN. 

Sclerema neonatorum, or scleredema, as it has been 
well called by Sol t maim, is exceedingly rare in the 
United States. In nearly 90,000 cases of skin diseases 
of all kinds reported to the American Dermatological 
Association, not a single case of this^ affection is re- 
corded. Meigs and Pepper, in their enc3 r clopsedic work 
on the " Diseases of Children," refer to one case occur- 
ring in the course of atelectasis pulmonum, and Hyde 



Hyper trophies of the Skin, 155 

refers in an indefinite manner to several cases seen by 
him. 

Indurative oedema of infants usually occurs before 
the sixth day of extra-uterine life. The children are 
languid, somnolent, and suckle with difficult}^. The res- 
piration is shallow, irregular, and slowed. Pulse and 
heart's action weak. Temperature much below the 
normal, in 1 case seen by Soltmann sinking to 60° F. 

The skin is tense, yellowish white, or mottled, and 
spotted with ecchymoses. The (edematous surfaces are 
firm and resisting, but will pit slightly on pressure. The 
induration usually begins in the calves of the legs and 
gradually extends over the body. 

The disease has no relation to scleroderma of adults. 
It generally occurs in weak, prematurely born infants. 
Unfavorable surroundings, defective nourishment, insuf- 
ficient protection against cold, and probably want of care 
and attention seem to be causative factors. The fact, how- 
ever, that even in France and Germany, where the disease 
is comparatively frequent, few cases are seen in private 
practice and nearly all in foundling asylums, points to 
a possible source of the disease in contagion or infection. 

The prognosis is exceedingly grave. The average 
mortality is from 80 to 90 per cent. According to 
Rayer, the recoveries are only from 1 to 2 per cent. 
Soltmann has never seen a case recover. 

In view of this mournful prognosis there can be little 
question of treatment. Keeping the little patient warm, 
giving stimulants internally, and applying embrocations 
externally comprise all the measures available. 

ELEPHANTIASIS ARABUM — ELEPHANT 's LEG. 

Elephantiasis arabum is endemic in tropical coun- 
tries, but is found sporadically in all parts of the world. 



156 Diseases of the Skin. 

It consists, essentially, of an obstruction and dilatation 
of Ivmpli-ducts, with consequent hyperplasia of con- 
nective tissue. The disease is sometimes congenital, 
but in the great majority of cases is acquired. It is 
neither hereditary nor contagious. 

The congenital form of elephantiasis has been well 
described in an exhaustive monograph by Dr. Samuel 
C. Busey, published under the title of u Congenital Oc- 
clusion and Dilatation of Lymph- Channels." 1 In this 
form there is great enlargement and grotesque deformity 
of one or more limbs. The skin is thickened, but not 
hard or discolored, although sometimes studded with 
irregular, soft elevations, which represent dilated lym- 
phatic vessels. In a case which I had the opportunity 
of seeing, through the courtesy of Dr. T. B. Evans, of 
this city, the part affected was the left arm. The patient 
was a white child, otherwise w^ell developed, but with 
great thickening and distortion of form of the affected 
limb. 

In the acquired form the disease is usually limited to 
one leg, although sometimes both limbs are affected. It 
also not infrequently attacks the genital organs, involv- 
ing scrotum and penis in the male, the labia, clitoris, 
and mammary gland in the female ; the lips, ears, or 
eyelids may also be the seat of the disease. I have seen 
one case, affecting the lower lids, in a middle-aged 
colored woman. The elephantiasis had followed an 
attack of erysipelas. I have also seen it affect the skin 
surrounding the anus, as a consequence of extensive 
neglected h hemorrhoids. 

Elephantiasis, as seen in temperate latitudes, is 
usually preceded by repeated attacks of erysipelatous 
inflammation. The inflammatory condition seems to 

1 New York : Win. Wood & Co., 1878. 



Hypertrophies of the Skin. 15? 

leave an obstruction of lymph-channels, which results 
in an accumulation of lymphatic fluid and consequent 
overproduction of connective tissue, having as effect 
thickening of the skin alone ; or the subcutaneous struc- 
tures, including nerves, muscles, and bones, may be 
involved. The part affected becomes very much en- 
larged, firm, but, in the early stages, pitting on pressure, 
and is generally more or less deformed, the normal 
shape of the limb or organ being lost as the malady 
progresses. 

The surface of the skin may be smooth, or rough, 
scaly, and uneven. It is often covered hy shallow, indo- 
lent ulcerations. 

When the scrotum is affected it often grows to enor- 
mous size. Cases have been reported where the scrotal 
tumor has weighed over one hundred pounds. The 
labia and clitoris are also much enlarged in some cases. 
Primer, who saw many cases of this disease in the East, 
sa}'S that scrotal elephantiasis is never preceded by 
erysipelas, and that the affection begins in a small, 
hard lump in the lower portion of the scrotal sac; but 
Manson's observations seem to contradict this. The 
testicles are not affected. 

The labia and clitoris are also very much enlarged 
in some cases. In many of the cases of elephantiasis 
pudendi, in temperate climates, there seems a close con- 
nection between syphilis and this disease. 

In Egypt, India, China, and South America ele- 
phantiasis is very frequent. Dr. Patrick Man son, of 
China, has expressed the opinion, indorsed b}' Fayrer, 
Lewis and Cunningham, and others in India, that 
elephantiasis is due to an animal parasite, — the filaria 
sanguinis hominis, which produces either embolism or 
inflammatory obstruction of the lymphatic vessels and 



158 Diseases of the Skin. 

glands. 1 Dr. Manson thinks lie has shown that ele- 
phantiasis arabiim, lymph-scrotum, and clryluria are all 
related diseases, and produced by the presence of the 
organism mentioned in the blood and lymphatic vessels. 

Outside of the endemic elephantiasis districts the 
disease is not produced by the filaria; but the essential 
pathological condition, occlusion of bvmph-vessels and 
glands, and consequent new formation of connective 
tissue, is the same. It is not improbable that the occlu- 
sion is the result of irritative inflammation in the 
lymphatics, and not of parasitic embolism, as supposed 
by Manson. This would explain those cases following 
erysipelatous and syphilitic inflammations. Dr. Ma- 
pother 2 believes that a dependent position of the part 
attacked is the principal condition prerequisite to the 
development of elephantiasis, as the lymph is obliged to 
rise against gravity, and any cause which produces in- 
activity of the muscles promotes lymph-stasis and exu- 
dation with consequent hyperplasia of connective tissue. 

Elephantiasis arabum should not be confounded with 
the disease called by the same name by the old Greek 
writers (elephantiasis Grsecorum). The latter disease 
is true lepros}-. As they do not resemble each other 
except in name, no difficulty is likely to arise in the 
differential diagnosis. 

In the early stages, before the proliferation of solid 
elements, appropriate treatment is often followed by 
much improvement. The inflammation is to be com- 
bated by ordinary antiphlogistic measures, and absorp- 
tion of the effused lymph promoted by bandaging, the 
application of mercurial ointments, and the administra- 
tion of iodide of potassium. 

1 Manson : The Filaria Sanguinis Honiinis. London, 1883. 
3 Philadelphia Medical Times. November 15, 1887. 



Atrophies of the Skin. 159 

The constant galvanic current has been used with suc- 
cess by Brazilian physicians. From what is now known 
of the absorptive powers of the cataphoric current, this 
seems a rationally indicated mode of treatment. 1 

Compression or ligation of the vascular supply of 
the affected part has been resorted to, but, except in re- 
cent cases, with little benefit. Amputation of the 
affected limb was first done by the late Dr. J. M. Carno- 
chan, of New York. It is, of course, a radical measure. 
When the scrotum or pudendum are involved, amputa- 
tion is the only mode of treatment indicated. Morton 
excised a portion of the sciatic nerve with asserted 
benefit in one case. Internal remedies are of no avail, 
except to relieve s3 r mptoms, or in the early stages, as 

mentioned. 

Atrophies. 

Atrophic disorders of the skin may affect the con- 
nective tissues of the skin, the pigment, or the hairs. 

ATROPHIA CUTIS — ATROPHY OF THE CONNECTIVE-TISSUE 
LAYER OF THE SKIN. 

The most familiar form of atrophy of the skin is that 
which occurs in the form of whitish, bluish, or pinkish 
lines on the abdomen of women, and which usually indi- 
cate a previous pregnane}'. This atrophic condition is 
due to excessive distension of the skin, and therefore 
not due solely to pregnane} 7 , but to any cause which 
may give rise to excessive stretching of the skin. 
Hence these stride atrophica are also found in ascitic or 
corpulent persons, as has been pointed out by Joseph 
Frank in the early part of this centur} 7 . 

In some cases the atrophy is due to a trophoneurosis. 
Wilson has described cases of linear atrophy due to 

1 See Liebig and Robe : " Practical Electricity in Medicine and Sur- 
gery." Philadelphia, 1890, p. 373. 



160 Diseases of the Skin. 

nerve influence. Schwimmer gives details of a case of 
universal cutaneous atrophy in a woman 25 years of 
age, in which there was marked degeneration of the 
cutaneous nerves. 

In the rare affection known as unilateral atrophy of 
the face, the skin is usually involved along with the 
muscles and other tissues. 

In old age more or less atrophy of the cutaneous 
tissue takes place, which has been thoroughly studied 
b} r Neumann. In this form there is a diminution of the 
tissue of the cutis, resulting in shrinking and thinning 
of the same. This is attended by alterations in texture 
designated as fine granular degeneration, senile shrink- 
ing, vitreous degeneration, and other modifications of 
nutrition. The atrophy of connective tissue is often 
accompanied b}' epithelial hyperplasias, such as warts, 
keratosis senilis, and sometimes atj^pical epithelial new 
formations (true epithelioma). 

Senile atrophy of the skin is frequently accompanied 
bj T intense itching, the condition usually termed pruritus 
senilis in the text-books. 

In most cases, very little can be done for the relief 
of cutaneous atrophy. The wrinkled skin of old age 
and of lean persons can be much improved, however, by 
a system of local treatment designed to improve its nu- 
trition. Systematic manipulation (massage), with the 
conjoined inunction of codliver-oil, olive-oil, lanolin, 
lard, spermaceti, or oil of sweet almonds, will produce a 
marked improvement in appearance in the dry, lustre- 
less, or wrinkled skin of persons of meagre habit, or of 
those who have passed the prime of life. A combination 
of 10 parts of spermaceti with 80 or 90 parts of oil of sweet 
almonds, perfumed to the taste, makes an elegant appli- 
cation. It should be carefully rubbed in at night, after 



Atrophies of the Skin. 161 

washing the skin with warm water and a mild soap 
(pure eastile being probably the best for this purpose), 
or the liniinentum saponis of the pharmacopoeia may 
be used as a detergent. In the morning the fat should 
be washed off with soap and warm water, and some 
emollient cosmetic lotion (Formula 56) applied. 

No treatment has } T et been successful for trophoneu- 
rotic hemi-atrophy of the face, or for the linear atrophies, 
or so-called " false cicatrices " of pregnane}'. 

ATROPHY OF PIGMENT — LEUCODERMA. 

Leucoderma means simply white skin. It is due to 
an absence of pigment in the epithelial layer of the skin. 
The condition — it can hardly be called a disease — may 
be congenital or acquired. The most marked forms of 
the congenital variety are seen in the albinos, which are 
exhibited in all the curio museums and circus " side- 
shows " in the country. These individuals are usually 
the offspring of the darker races, but may be descend- 
ants of the white race. In addition to the milky or 
pink-tinted skin the hair is usually white or light yellow, 
and the iris red, owing to absence of the characteristic 
iridian pigment. 

The congenital form of leucoderma may also be 
partial. This is seen not very infrequently in those 
persons who have a lock of white hair upon the head, or 
a bundle of white hairs among the beard. This white 
hair usually grows from a perfectly pigmentless patch 
of skin. 

In the acquired form of leucoderma, generally called 
vitiligo, the same anatomical condition exists. The 
white spots or patches are round, oval, or irregular, 
smooth, with normal sensation and vascularization. 
They are perfectly flat, and neither elevated above nor 

G 2 



162 Diseases of the Skin. 

depressed below the level of the skin. There are no 
subjective sensations, such as itching, burning, tingling, 
or numbness. The hair upon the white spots some- 
times preserves its normal color, and in others is also 
devoid of pigment. 

A peculiar effect is produced upon the non-pigmented 
patches by intense sunlight. While the normally pig- 
mented skin tans and becomes bronzed by exposure, the 
white spots either remain unaffected, or become red, 
inflamed, and painful. 

Partial acquired leucoderma is not very rare among 
negroes, in whom it produces very grotesque effects. 
The daity papers frequently contain sensational accounts 
of negroes " turning white," as if the phenomenon was 
an extremely rare one. In the less extensive forms it 
is comparatively often seen among whites, and is ap- 
parently more frequent in the South. It is usually 
symmetrical, and seems to be governed to a certain 
degree by the nervous distribution in the skin. 

The causes of the affection are obscure. In some 
cases a connection can be traced between the disappear- 
ance of the pigment and some traumatic influence, but 
in most instances no etiological relation can be made 
out. It has no connection, so far as known, with any 
disorder of any internal organ. 

The borders of the white spots are usually a little 
darker than the normal tint of the skin, giving the 
impression that the cutaneous pigment is produced in 
the usual quantity, but is abnormally distributed. 

Certain cases of leprosy (lepra maculosa), or the 
atrophic stage of morphcea, may, on superficial observa- 
tion, cause mistakes in diagnosis between these diseases 
and leucoderma, but a careful examination of the lesions 
will enable one to make the differentiation with the 



Atrophies of the Skin. 163 

greatest ease. In fact, it is difficult to see how an 
observant physician can confound such a simple local 
disorder as leukoderma with a grave constitutional dis- 
ease like lepros3 r . 

We know so little of the conditions under which 
pigment is normally formed in skin, that all attempts to 
restore it, when absent, must be purely empirical. 

The treatment of leucoderma has hitherto been very 
barren of results. In one case, in which I was requested 
to suggest some remedy, I advised a long-continued 
course of arsenic, with the apparent effect of producing 
improvement. Whether the improvement was due to 
the remedy, or whether it was maintained, I am unable 
to say. At all events, this remedy is worth trying. 

When the affection appears upon the face, the 
brownish border of the spots, which throws the white 
surface into strong relief, may be rendered lighter by 
the local applications recommended against chloasma 
(q. v.). 

It should be mentioned that the normal color of the 
skin sometimes returns spontaneously in acquired leuco- 
derma. 

ATROPHY OF THE HAIR — ALOPECIA. 

Baldness is either temporary or permanent. It may 
be due to disease of the hair-follicles or perifollicular 
tissues, or it may be symptomatic of some constitutional 
disorder. It is generally classified in the books as 
premature and senile baldness, but this classification is 
defective, since many persons reach old age without 
losing their hair. Baldness is, therefore, not an attri- 
bute or necessaiy consequence of advanced life. 

In syphilis, convalescence from fevers, or other grave 
or depressing diseases, temporary baldness is frequent. 
In these cases the hair nearly always returns in a luxu- 



164 Diseases of the Skin. 

riant growth ; but, unless the hygiene of the scalp is 
care full}- attended to, the defluviuin begins again in a 
short time, attended by seborrhoea or dandruff, and 
eventually results in permanent baldness. 

"Dandruff" is an almost universal precedent of 
those cases of early baldness not dependent upon some 
constitutional condition. It is generally regarded by 
dermatologists as an evidence of seborrhoea, although 
some observers deny this. The view that dandruff and 
the consequent alopecia are parasitic affections has been 
asserted by a number of pathologists, but, up to the 
present time, no satisfactory evidence has been furnished 
in its favor. 

Parasitic skin diseases, such as ringworm or favus, 
sometimes cause baldness, which is in most cases only 
temporary. After the parasite has been destroyed and 
the irritation of the skin subdued, the hair usually 
grows again, unless, as in cases of kerion or sycosis, 
the hair papillae are destroyed by the intensity of the 
inflammatory action. The hair sometimes falls out in 
eczema and psoriasis of the scalp, but is usually re- 
stored after the skin disease is cured. Of course, 
ulcerative diseases which heal only by the formation 
of cicatricial tissue preclude the regeneration of the 
hair, where the hair-papillae have been involved in the 
ulcerative process. 

Early baldness is attributed to many causes, some 
plausible, man}^ fanciful. Thus, close cropping of the 
hair, wearing a covering on the head most of the time, 
and the habitual daily use of water on the scalp have 
been accused of hastening the falling out of the hair. 
None of these are, in my opinion, sufficient to account 
for the alopecia. Thus, soldiers, who keep their hair 
closely cropped most of the time, do not suffer more 



Atrophies of the Skin. 165 

from baldness than do other persons. Cleanliness, 
which is certainly fostered by the ablution of the scalp, 
should not be accused of producing this deformity, 
without very definite evidence. The statistics of El- 
linger in reference to this point, upon which so much 
reliance is placed by some writers, require confirmation 
before they can be accepted without reserve. 

The view that the constant wearing of a head-cover- 
ing tends to produce falling out of the hair is, I be- 
lieve, entirely fallacious. Persons who keep their heads 
covered most of the time are, according to my obser- 
vation, less liable to baldness than those who have the 
scalp frequently uncovered. In fact, my observation 
leads me to believe that keeping the head covered with 
a soft, well-fitting cap or hat tends to preserve the hair. 
That an ill-fitting hat, compressing the blood-vessels 
and tissues unequally, interferes with the proper nu- 
trition and growth of the hair is quite plausible and 
deserves consideration. 

There can be no question that heredity plays a part 
in the causation of baldness. 

The striking form of baldness known as alopecia 
areata, or area Celsi, is probably a neurotic affection, 
although several prominent dermatologists hold to the 
view that it is of parasitic origin. The published 
evidence in favor of the latter is insufficient to over- 
throw the prevailing belief. This form of alopecia 
usually occurs suddenly, large bunches of hair coming 
out over a distinctly limited surface, and leaving the 
spot completely bare, smooth, uninflamed, and shining. 
No known parasitic disease has such a history. Besides, 
the hair frequently grows again without any local para- 
siticide treatment, although the latter, by its irritant 
effect, may stimulate the growth to greater rapidity. 



166 Diseases of the Skin. 

The treatment of the defl avium depending upon 
acute diseases comprises such remedies as will raise the 
general nutrition. In syphilitic alopecia the specific 
treatment appropriate to the case will improve the 
capillary growth. In the alopecia of convalescence, 
cleanliness of the scalp with the daily use of some 
stimulant lotion are indicated. A combination which 
I have used with much satisfaction in cases of falling 
out of the hair in syphilis or after acute febrile diseases 
is given in Formula 57. 

This is to be well rubbed into the scalp nightly. 
Sometimes the addition of half a dram [2.] of carbolic 
acid is an improvement. If the hair is very dry the 
proportion of glycerin may be slightly increased. 
This prescription is also an excellent one in those cases 
of baldness not accompanied by dandruff, and in which 
there seems to be only a deficient force in the growth 
of the hair. 

In the baldness due to or accompanied by dandruff, 
or dry seborrhoea of the scalp, and which constitutes 
about nine-tenths of the cases that apply for treatment, 
I have found the following method very efficient : The 
scalp is washed two or three times a week with a good 
tar soap, and afterward a lotion containing either sul- 
phur or resorcin (Formulae 58, 59) is applied and well 
rubbed in. 

A small quantity of glycerin or castor-oil may be 
added to either of the prescriptions if the scalp is very 
dry. If preferred, an ointment (Formulae 60, 61, 62) 
may be used instead of the lotion. 

A mild ammoniated mercury ointment is also often 
useful. 

The treatment of alopecia areata is often unsat- 
isfactory. The local treatment should be a stimulant 



Atrophies of the Skin. 167 

one ; lotions or ointments containing capsicum, can- 
tharides, iodine, or similar active ingredients should be 
used to the bald patches and rubbed in with consid- 
erable friction. The galvanic and farad ic currents also 
promise good results. Internally, neurotic tonics ; qui- 
nine, iron, strychnine, and phosphorus are generally 
indicated. 



NEW FORMATIONS OF THE SKIN 

(By J. Williams Lord, A.B., M.D.) 



The new formations of the skin do not differ, patho- 
logically, from these growths in other organs. They 
often present clinical peculiarities, however, which de- 
mand consideration. 

I. Epithelial New Formations. 

EPITHELIOMA. 

The form of carcinoma which is most frequently 
encountered upon the skin and the adjacent mucous 
membranes is known as epithelioma, skin cancer, or 
epithelial cancer. 

It is a malignant new growth, composed of epithelial 
cells, derived from the rete mucosum, which invade the 
corinm and subcutaneous tissue in all directions, replac- 
ing and infiltrating the normal elements, and, by their 
presence, give rise to more or less irritation and inflam- 
mation, with subsequent destruction of tissue. It is at 
first a local disorder, occupying but a limited area of 
the skin, with a tendenc}^ always to progressive exten- 
sion, botli in surface and depth, but often requiring 
months or years before much advancement is made; it 
finalty involves and destroys all tissues, skin, muscles, 
fascia, cartilage, bones, and lymphatic glands ; metas- 
tasis is then liable to occur, and the individual succumbs 
from septic poisoning or exhaustion. 

There are two varieties of epithelioma (the squamous 
and the cylindrical, or columnar), the distinction between 
(168) 



New Formations of the Skin. 169 

them resting upon the form of the cell-elements which 
are 'present. The former is found upon those parts in 
which there is squamous or pavement epithelium ; as, 
for example, the skin and the mucous membranes lining 
the outlets of the bod}', viz., the mouth, lower portion 
of the rectum, vagina, etc. The mucous membrane of 
the gastro-intestinal tract, bladder, uterus, and laiynx 
possesses columnar cells ; and hence, in these regions, 
the cylindrical epithelioma is developed. 

The squamous epithelioma alone requires descrip- 
tion, as it is the variety commonly encountered by the 
dermatologist. 

It may begin in many ways, — either upon the healthy 
skin or from various growths, such as warts, moles, or 
patches of horny seborrhcea. Clinically, three forms of 
squamous epithelioma are noted, owing to the differences 
in their mode of development, course, and general ap- 
pearance. These are the superficial, the deep-seated, 
and the papillary varieties. They agree, however, with 
respect to their intimate nature. 

The superficial or flat variet3 T involves all portions 
of the skin, and begins as a slight excoriation or fissure, 
which refuses to heal, or in the form of one or more 
small reddish or yellowish papules, placed close together, 
resembling a wart. In the course of time the growth 
shows a tendency to crack and fissure, and a thin, sticlsy, 
serous fluid, sometimes mixed with a little blood, exudes, 
which dries into brownish or blackish crusts. These 
fall off, or are picked off, leaving the surface beneath of 
a bright-red color ; this soon becomes crusted over 
again; the growth gradually enlarges, both along the 
periphery and in depth, until it has attained the size of 
a pea or dime, when it breaks down into an ulcer. The 
ulcer is usually round or oval, at first quite superficial, 

8 H 



HO Diseases of the Skin. 

and is covered with a brownish scab, which, when 
removed, reveals the base of the ulcer, covered with 
reddish gran illations, bathed in a serous, scanty fluid. 
Its edges are everted and hard. This form of epithel- 
ioma lasts an indefinite period, — it maj- be for years, — 
causing but slight disturbance, the ulcer finally healing ; 
or else it passes on into the deep-seated variety, with 
implication of the lymphatic glands. 

The deep-seated variety begins in the deeper portions 
of the cor him and subcutaneous tissue, in the form of a 
firm, hard tubercle or nodule, the size of a pea or bean, 
distinctly raised above the surface. It increases rapidly 
in size, is of a reddish or purplish color, and the sur- 
rounding skin is found to be infiltrated for some distance 
and darker in color. This variety is painful from the 
very beginning, the pain increasing in intensity and be- 
coming lancinating, when the destructive process shows 
itself. A few months generally suffice for the growth to 
ulcerate. The ulcerative process starts from the surface 
or the interior of the growth, and spreads rapidly, caus- 
ing extensive destruction of all tissues. The lymphatic 
glands are soon involved, metastasis to other organs 
may occur, and death takes place in from one to four 
3 7 ears, the patient being worn out by pain and exhaus- 
tion. The ulcer is deep, round or irregular in shape, 
with everted or undermined hard edges ; its base is un- 
even, and covered with red granulations; it bleeds 
readily when touched. 

The papillary variety is the result of the invasion of 
the papillae of the skin or of the mucous membranes. 
It is most frequently met with upon the mucous mem- 
branes, and appears in the form of a wart, or of a 
fungating, cauliflower-like growth, varying greatly in 
size. It also becomes fissured, and finally undergoes 



New Formations of the Skin. HI 

ulceration. It is at first quite superficial, and ma} 7 last 
for years, especially when upon the skin ; but, sooner or 
later, it passes into the deep-seated variety. It is the 
most malignant form of epithelioma. 

The regions commonly invaded b} 7 the epitheliomatous 
process are the face, the various outlets of the body, and 
the genitals. Upon the face the growth usually makes 
its appearance about the eyelids, especially the inner 
canthus, cheeks, root and alse of nose, and forehead ; 
upon the lower lip and tongue, the penis, and scrotum ; 
about the anus and the lower two and a half inches of 
the rectum ; in the vagina, the portio vaginalis of the 
uterus, and the labia. It may appear, however, upon 
other portions of the body. The superficial form usu- 
ally occurs upon the face, the deep-seated upon the lips, 
and the papillomatous upon the penis, vagina, and 
rectum. 

This disease represents about one-half of 1 per cent, 
of all skin affections. It occurs much more frequently 
in males than in females, probably on account of the 
former being more exposed to the exciting causes. It 
usually makes its appearance after middle life, — from 
the forty-fifth to the seventieth year. It is rarely seen 
under forty years, though cases have been recorded in 
children. In a few cases heredity can be assigned as a 
cause. As an exciting cause long-continued irritation 
plays an important role in its development. 

Epithelioma upon the lower lip and tongue frequently 
results from the irritation of a pipe-stem. Chronic ulcers 
are liable to degenerate into epithelioma; and this is 
true of syphilitic and lupous ulcers. Scar-tissue from 
burns and injuries also undergoes this change. Epi- 
thelioma is prone to occur in warts, moles, and vascular 
naevi. 



172 Diseases of the Skin. 

A microscopical specimen of epithelioma shows 
that the process consists of an inflammatory condi- 
tion of the skin and the growth of epithelial cells from 
the rete, in the form of interpapillary prolongations, 
from which processes are given off in various direc- 
tions, and unite with each other until, finalty, the whole 
skin becomes invaded by the cell growth. The epithe- 
lial cells, through pressure, become arranged in the 
form of nests or globes. The vascular supply is quite 
extensive. From the crowding of the cells together 
the blood-supply is cut off and fatty degeneration 
ensues; the tissue becomes absorbed, or is cast off by 
ulceration. 

Diagnosis. — Epithelioma is to be differentiated from 
an ordinary wart, syphilis, and lupus. As a rule, there 
is but little difficulty in the diagnosis. The following 
points should be borne in mind : Epithelioma is a dis- 
ease of middle and advanced life ; it is usually a single, 
painful growth, and occurs in the form of a Assured 
wart or an excoriation which refuses to heal under treat- 
ment. Attention should be paid to the history and 
course of the disease. 

A simple wart does not undergo any change, nor is 
it painful. Syphilitic lesions, whether tubercles or 
ulcers, are usually numerous, not attended by pain, run 
a rapid course, and appear in early adult life. Lupus is 
a disease of childhood ; its lesions are numerous, and it 
never invades bone. 

Treatment. — The treatment consists in the removal 
of the growth as soon as possible, and a considerable 
portion of the surrounding apparently healthy tissue. 
This may be accomplished by caustics, erasion, or ex- 
cision, and by the galvano-cauteiy, — methods which are 
similar to those employed in lupus vulgaris. 



New Formations of the Skin. 173 

II. Connective-Tissue New Formations. 

keloid. 

Keloid is a new growth, composed of connective 
tissue, situated in the corium. It consists of one or 
more variously sized, irregularly shaped, more or less 
elevated, firm, smooth, reddish, scar-like tumors. 

Two forms of this disease are described, depending 
altogether upon the mode of origin, for in their intimate 
nature and external appearance they are identical. In 
the one form the growth arises spontaneously, and has, 
therefore, been termed true or spontaneous keloid. In 
the other variety the growth appears upon the site of a 
scar, or upon that portion of skin which has sustained 
an injury, and is known as false or scar keloid. The 
cause of keloid is not known. It is observed to follow 
the scars of small-pox, acne, and syphilis ; on the site 
of leech-bites ; after vesicular and pustular eruptions ; 
also, after burns by fire or chemicals, surgical operations, 
and floggings. The growth occurs with about equal 
frequency in each sex. It is more common in the negro 
race. It appears usually in adult life, rarely occurring 
before puberty. 

In the beginning, one or more pea-sized or larger 
nodules, firmly imbedded in the skin, develop and slowly 
increase, until, in the course of several years, the growth 
may attain a considerable size, varying from one to two 
inches in diameter to the size of the palm or larger. 
The tumor does not enlarge steadily from year to year, 
but at times takes on rapid growth. Having reached a 
certain size, the process ceases, and the growth remains 
throughout life, or else undergoes spontaneous involution. 

Usually but one tumor is present, which is firm, raised, 
circumscribed, sharply outlined, of an oval, elongated, 



174 Diseases of the Skin: 

or irregular shape, flattened and smooth, reddish or 
pinkish in color. Occasionally it presents processes 
which spread out like the claws of a crab, whence its name. 

The usual seat of the disease is upon the trunk, 
especially over the region of the sternum and along the 
intercostal spaces. It may occur upon other portions 
of the body, — as the neck, lobules of the ear, extrem- 
ities, and the genitals ; rarely is it met with on the face. 
At times there is pain. Other symptoms — as itching 
and burning— xire often presenf. 

It is a benign growth, and is never attended by 
ulceration. It is composed of dense bundles of white 
fibrous, connective tissue, interspersed with few spindle- 
shaped cells arranged along the blood-vessels. The 
fibres run parallel to the surface of the skin. 

Diagnosis is easy. The disease usually continues 
throughout life, but occasionally disappears spontane- 
ously. 

The treatment hitherto followed has not proven of 
much benefit. Excision of the growth, and even of the 
adjacent skin, is almost invariably followed by a return 
of the disease. The same result follows the use of 
caustics. Multiple scarification, as practiced in lupus, 
has given some satisfaction, but the best results have 
followed the use of electrolysis. Hardawa} r , of St. 
Louis, and Brocq, of Paris, have reported successful 
cases. For the relief of pain hypodermatics of mor- 
phine or cocaine m&y be given. Pressure by the elastic 
bandage is sometimes followed by absorption and disap- 
pearance of the growth. 

FIBROMA. 

Fibroma is a benign tumor, formed of connective 
tissue, which has its seat in the skin or subcutaneous 
structures. There may be a single growth. 



New Formations of the Skin. 1T5 

Usually, however, many are found scattered over the 
body, scalp, face, trunk, and extremities, varying in size 
from a pea to a cherry or even as large as a head, some- 
times weighing many pounds. They are rounded, semi- 
globular, or pear-shaped, attached to the skin by a broad 
base or else by a thin stalk. When single they may 
attain a great size, and are apt to be pedunculated. 
The skin over these tumors is loose or tense, of its 
normal structure and color, or of a reddish hue. They 
are firm or soft to the touch. There is no pain connected 
with them, but a feeling of weight and discomfort 
may attend the larger growths, and they may prove a 
source of annoyance when occurring upon the scalp or 
face. 

The cause is unknown. Several members of a family 
may be afflicted, and heredity can be assigned in some 
cases, as the disease shows itself in several generations. 
It usually makes its appearance in childhood, growing 
slowly and progressively, and becoming more pro- 
nounced in adult life. 

It is of rare occurrence, and' usually continues 
throughout life, but does not interfere with the general 
health. 

It is to be differentiated from molluscum contagi- 
osum, neuroma, and lipoma. Molluscum contagiosum 
is a superficial growth and presents a central depression, 
through which its contents can be expressed. Fibroma 
is deeper-seated, the skin normal. 

Neuroma is an extremely painful, very rare affection, 
and occurs along the course of a nerve. 

Lipoma is a soft, lobulated tumor. 

Treatment. — Removal of the growths b}^ the knife, 
when not too numerous; if large and pedunculated, 
by the ligature or galvano-cautery. 



176 Diseases of the Skin. 

XANTHOMA. 

Xanthoma is an affection of rare occurrence, usually 
met with after middle life. It presents itself in the form 
of small, yellow patches, or of yellowish tubercles. The 
patches, varying in size from a pin-head to a pea or 
larger, are encountered on the eyelids, beginning at the 
inner canthus. The disease is usually symmetrical. 
The patches are sharpty defined, smooth, on a level with 
the skin or slightly raised, and resemble pieces of cham- 
ois-leather. They increase in size slowty. There are no 
subjective sensations connected with them. The tuber- 
cles are pea-sized and larger, soft, of a yellow color, and 
occur on various parts of the body, the eyelids being 
usually exempt. They appear on the trunk, the extremi- 
ties, over the elbows, knees, and knuckles, and at times 
are quite painful. Xanthoma is not limited to the skin, 
but involves the mucous membranes of the mouth, the 
larynx, and trachea. Patches are found on the internal 
organs, the liver, and spleen. In a majority of cases the 
disease is associated with, or preceded by, jaundice. It 
is of more frequent occurrence in women. It is a new 
growth, composed of connective tissue and of fusiform 
and stellate cells, containing yellowish pigment and oil- 
drops, having its seat in the corium. 

Treatment consists in the removal of the growth 
when necessaiy by excision or by electrotysis. Care 
should be taken not to remove too much of the skin in 
the eyelids, as the resulting scar may cause ectropion. 

RHINOSCLEROMA. 

Rhinoscleroma is a dense, hard growth, somewhat 
elevated, more or less flattened and irregular, composed 
of firm nodules, of the color of the skin, or of a brown- 
ish hue. It appears about the alae and septum of the 



i 



New Formations of the Skin. 177 

nose, extends slowly to the upper lip and to the adja- 
cent mucous membrane. At first the parts are swollen, 
but not inflamed; the tip of the nose is rigid; the epi- 
dermis shows a tendenc} r to crack, and secretes a fluid 
which dries into crusts. In time the nostrils become 
partially or completely closed. There are no subjective 
sensations, except pain on pressure. The general health 
does not suffer. There is no disposition to involution 
or ulceration, the growth being steadily progressive and, 
if removed, rapidly returning. The disease is of rare 
occurrence in this country. It first shows itself after 
pubertj'. The process consists in a round-celled infiltra- 
tion into the papillae and superficial layer of the corium, 
the epidermis being normal. 

Treatment. — Removal of the diseased tissue is neces- 
sary. This may be effected by caustics, such as the 
solid stick of caustic potash, of nitrate of silver or 
pyrogallic acid, or by excision of the growth. 

SARCOMA. 

Sarcoma of the skin is a malignant new growth, 
which develops directly from the connective-tissue la} T er 
of the skin or from the subcutaneous tissue, subsequently 
implicating the skin, or it occurs here secondary to its 
presence in some internal organ or lymphatic gland. 
Sarcoma, when it invades the skin primarily, usually 
spreads rapidty over the surface, and by metastasis is 
conveyed to the internal organs. 

It appears as pigmented or non-pigmented tumors, 
and as fungoid growths. They are single or multiple, 
usually the latter, and are found all over the body, be- 
ginning generally about the hands and feet, on both sur- 
faces, and spread slowly or rapidly up the arms and legs 
to the face and trunk. The tumors, varying in size from 

8* 



178 Diseases of the Skin. 

2l shot to a hazel-nut or larger, are smooth, firm, and elas- 
tic. At first discrete, they after a time coalesce and 
give rise to various sizes and shapes. The non-pig- 
mented sarcoma is of a reddish color, while the pig- 
mented is blue or black, somewhat painful on pressure, 
and occasionally spontaneously painful. They exhibit 
a tendenc}^ to ulceration. Death usually takes place 
in the course of one to three years, from internal com- 
plications or exhaustion. It is a rare disease, more 
frequent in men, and appears after middle age. It con- 
sists of a small or large, round or spindle-celled infil- 
tration into the corium, with more or less pigmentation 
and haemorrhages. The growths are quite vascular. A 
pigmented mole is often a starting-point of the disease. 
Treatment is palliative. The disease tends to a fatal 
termination. Excision of the tumors is invariably fol- 
lowed by a rapid return of the growth. According to 
Kobner, subcutaneous injections of Fowler's solution 
of arsenic, from 2 to 4 drops, diluted with distilled 
water, and gradually increased to 10 drops daily for 
several months, have been followed by disappearance 
of the growths. 

LEPRA — LEPROSY. 

Leprosy is a constitutional, contagious disease, due 
to a specific poison. It involves all the tissues of the 
body, manifesting itself by lesions of the skin, mucous 
membranes, nerves, lymphatic glands, bones, and internal 
viscera. The lesions consist of new cell formations, and 
the symptoms, which are both general and local, are the 
result of this new growth. The disease develops slowly 
and insidiously, pursues an exceedingly chronic course, 
and terminates fatally, — either from complications which 
are liable to ensue within the lungs, kidneys, or intes- 
tines, or from exhaustion and the leprous cachexia. 



New Formations of the Skin. 179 

This disease has existed from the most remote 
periods, and at one time was quite prevalent in Europe. 
By means of isolation, it was nearly stamped out of 
Europe at the close of the sixteenth century* In cer- 
tain countries it is endemic, — notably in India, China, 
Egypt, along the coasts of Africa, and about the Med- 
iterranean, Spain, Portugal, Norway, Iceland, Australia, 
the Sandwich Islands, Brazil, Central America, West 
Indies; several colonies are found in California, Lou- 
isiana, and Minnesota ; sporadic cases occur elsewhere 
throughout the United States. 

Man}^ symptoms, which are not at all characteristic, 
usually precede the active manifestations of the disease. 
These premonitory symptoms may be slight or severe, 
and may exist for months and years without exciting 
suspicion as to the nature of the affection, unless occur- 
ring in a leprous district. They consist of malaise, 
languor, weariness after slight exertion, pains in the 
muscles of the legs, mental hebetude, nausea, occasional 
diarrhoea, and fever of an intermittent type. In the 
course of time, the outbreak peculiar to the disease 
appears. According as one or another form of lesion 
predominates, or exists alone, different varieties are 
described. There are two distinct forms (the tubercular 
and the anaesthetic), and occasionally both are met with 
in the same individual. 

Tubercular Leprosy. — This variety is usually pre- 
ceded by certain premonitory symptoms, especially by 
chills and fever of an intermittent type. Eiysipelatous 
inflammations occur from time to time, following which 
bullae similar to those of pemphigus appear, localized 
about the hands or other portions of the bod}^, few or 
many in number. They rupture and leave pigmented 
spots behind. Yellowish spots also appear upon the 



180 Diseases of the Skin. 

trunk and extremities, and, in time, become anaesthetic. 
Sooner or later, yellowish-brown tubercles, varying in 
size from a pea to a walnut, develop upon the face and 
extremities. They are close together, with deep furrows 
between them. Much disfigurement results, the counte- 
nance assuming a leonine expression. The tubercles 
remain unaltered for an indefinite period, absorption 
occasionally taking place. About the hands ulcera- 
tion sometimes occurs, and the ulcers are difficult to 
heal. Tubercles, also, are met with on the mucous 
membranes of the mouth, pharj^nx, larynx, eye, and 
elsewhere. 

Anaesthetic Leprosy. — This form is usually preceded 
by chilly sensations, nausea, and by sharp, darting pains 
in the course of certain nerve-trunks, numbness, itching, 
and burning. After a while, pale, yellowish, smooth 
patches, varying in size and on a level with the skin, 
with violaceous borders, appear, one after another, until 
a considerable portion of the bocty is involved. At first 
the patches are somewhat hyperaesthetic, and more or 
less itching and burning sensations are present ; later, 
they become anaesthetic. Even portions of the skin 
upon which no patches are present become anaesthetic. 
Bullae frequently show themselves in an irregular man- 
ner, rupture, and leave pigmented spots. The anaes- 
thetic patches occur, for the most part, about the 
shoulders and back, the hands and feet, and the ex- 
tensor surface of the limbs. The skin becomes atrophied, 
more or less wrinkled, and yellow. The subcutaneous 
tissue, muscles, hair, and glands undergo a similar 
change. From wasting of the muscles and from paral- 
ysis the fingers are contracted and deformed, — some- 
what claw-shaped. Ulceration takes place about the 
joints, the process continuing until the fingers drop off. 



New Formations of the Skin. 181 

Sometimes the bones are absorbed, the tissues shrivel, 
and the fingers become distorted, without ulceration. 

Leprosy seems to be moderately contagious. It is 
probably contracted, by inoculation, during the sexual 
act. It is due to a specific germ, — the lepra bacillus. 
Climate, soil, food, and heredity act as predisposing 
causes. The disease may occur at any age, usually, 
however, in early adult life. The prognosis is unfavor- 
able ; all varieties end fatally, though such a termina- 
tion may be postponed by judicious treatment. Death 
ensues as the result of the direct effects of the disease, 
or from intercurrent complications. 

Diagnosis. — No error need arise when the disease is 
well established. The prodromal s} T mptoms may be 
mistaken for malaria, but in regions where leprosy is 
endemic such symptoms should arouse suspicion. The 
macular and tubercular leprosy is most likely to be 
mistaken for syphilis. In the latter affection the lesions 
occur on various portions of the body at the same time, 
are smaller than those of leprosy, and are not anaes- 
thetic ; nor do they remain in one form any length of 
time. The history of the cases is entirely different. 
The macular patches of leprosy are large, have a firm 
feel to the touch, last an indefinite time, and are more 
or less anaesthetic. 

Vitiligo, or leucoderma, is a pigment affection, con- 
sisting in the loss of pigment in patches, with an in- 
crease along the borders. To the touch, the skin is 
normal. There are no constitutional symptoms. 

Treatment. — Attention should be given to the con- 
dition of the general health : change of residence, good 
food, tonics, hygiene, exercise. There is no cure for 
the disease. Good results have been obtained from the 
administration of chaulmoogra-oil and gurjun-oil inter 



182 Diseases of the Skin. 

nally, in doses of 5 to 10 minims, and also rubbed in 
externally. When there is paralysis, the galvanic cur- 
rent may be emploj^ed. 

SCROFULODERMA. 

This is a localized manifestation upon the skin of a 
general condition known as scrofulosis. It consists of 
certain suppurative and ulcerative processes, the result 
of the deposit of granulation-like masses of cells, either 
in the lymphatic glands or in the subcutaneous tissue. 
The disease begins by the involvement of the lymphatic 
glands or by the development of subcutaneous nodules, 
which slowly enlarge, become prominent, unattended by 
inflammatory symptoms, and are freely movable beneath 
the skin. The glands remain in this condition an 
indefinite period, but, sooner or later, soften and break 
down, the skin becoming adherent, of a dull-red or 
violaceous color ; suppuration occurs, an abscess forms, 
with, finally, a discharge of a thick, creamy, cheesy pus, 
or of a thin, sanious fluid. The resulting ulcer is oval 
or irregular in outline, with thin edges; the adjoining 
skin of a violaceous color, and more or less under- 
mined by sinuses, which burrow in various directions. 
The base of the ulcer is uneven, covered with pale, 
flabby granulations, bathed in pus, which bleed readily. 
The ulcer secretes a thin, scanty fluid, mixed with 
blood, which dries into thin, brown crusts. The ulcera- 
tive process is slowly progressive, and shows no dispo- 
sition to heal. The scars which form are hard and 
contracted. The ulcers are seen frequently about the 
neck and face, though few in number. Other evidences 
of the strumous condition are generally present, such as 
enlarged glands, otorrhoea, blepharitis, coryza, and 
joint affections. 



New Formations of the Skin. 183 

All those conditions which impair the general 
health act as predisposing causes, as heredity, bad food, 
dark, damp dwellings, impure air, and the like. The 
active cause is the tubercle bacillus. 

The disease appears in childhood or early adult life, 
and is more frequent in the colored race. 

The treatment consists in the internal administration 
of alteratives, the syrup of the iodide of iron, codliver- 
oil, etc. The enlarged glands should be removed. If 
suppuration has occurred, open and scrape away all of 
the diseased gland by the dermal curette ; follow with 
iodoform ointment, 1 drachm to the ounce [1 to 8]. 
The granulations will need stimulation occasionally 
with the solid nitrate of silver. 

LUPUS ERYTHEMATOSUS. 

It begins by the formation of small, red, or viola- 
ceous patches, one or more in number, from a pin-head 
to a pea in size, sharply defined against the sound skin, 
slightly elevated at the margin, the surface smooth, or 
covered with scanty, thin, or thick, grayish, sebaceous 
scabs, more or less firmly adherent ; and these, when 
removed, show prolongations on their under surface, 
which dip down into enlarged sebaceous follicles. Come- 
dones are met with along the border. The individual 
patches increase in size by peripheral extension, and 
may assume large dimensions. Many of the patches 
coalesce, various shapes resulting. The patches are 
usually round or oval, but may be irregular. With the 
enlargement along the border, the central portion 
undergoes a retrograde change, becoming depressed, 
pale, and atrophic. The disease pursues an exceedingly 
chronic course, lasting for years, with periods of quies- 
cence, of improvement, and of rapid advancement. 



184 Diseases of the Skin, 

After awhile it remains stationary. Spontaneous invo- 
lution may occur, the skin returning to its normal 
condition, or else it is replaced by thin, atrophic scars. 
Frequently the process lasts throughout life. 

The region invaded is, in the majority of cases, 
limited to the nose and cheeks. Beginning on the 
bridge of the nose, it spreads symmetrically over the 
cheeks, assuming the figure of a butterfly. It is met 
with, however, on all portions of the body, next in fre- 
quency upon the tip of the nose, the lips, ears, forehead, 
scalp, hands, feet, and trunk. 

In some instances, the disease begins in the form of 
small, pea-sized patches, scattered over the body. These 
do not enlarge, but, by the development of new lesions, 
ultimately almost the entire surface may be invaded. 
This variety is attended with severe constitutional 
symptoms, and in many cases is fatal. 

Lupus erythematosus is the result of a small-celled 
infiltration into the corium, beginning around the seba- 
ceous glands and hair-follicles, in most cases. Any 
part of the corium, however, may be the starting- 
point of the disease; the superficial as well as the 
deep layer. It may begin, also, in the neighborhood 
of the sweat-glands. Sometimes the cells are absorbed, 
and the skin returns to its normal state.; at other 
times, partial degeneration and absorption occur, fol- 
lowed by the development of new connective tissue and 
scars. 

The process is always a dry one ; pus never forms. 
The lesions. are firm to the touch. 

This affection is met with mostly after middle life. 
Women are more liable to this disease than men. Those 
causes which produce a seborrhcea ma}' aid in its devel- 
opment. It is of rare occurrence. The general health 



New Formations of the Skin. 185 

remains good, except when the disease is in a dissemi- 
nated form. 

When fully developed, the diagnosis is easy. The 
following points are characteristic: The age at which it 
begins; the sharply outlined, raised margin; the sym- 
metrical arrangement ;' the color ; the atrophic change 
in the central portion of the patch ; its closely adherent 
sebaceous scales, with prolongations into the follicles ; 
its chronic course, and the absence of ulceration. 

Lupus vulgaris, while limited, for the most part, to 
the face, nevertheless differs from lupus erythematosus 
in many respects. It is a disease of childhood ; the 
patches are composed of papules and tubercles, with 
subsequent ulceration and scarring. 

An eczema is of a brighter-red color; the edges are 
not raised, but fade away gradually; itching is severe, 
and there is always a history of oozing, at one time or 
another, in its course; its features change often. 

Treatment. — Constitutional treatment proves of 
slight benefit. Codliver-oil, arsenic, phosphorus, iodide 
of potash, and a general alterative course may be tried. 
Most good is to be derived from local measures. Sapo 
viridis, rubbed in or allowed to remain for some time, 
applied on cloth ; mercurial plasters. An ointment of 
the bichloride of mercury, gr. ij to §j [1 to 250] ; pyro- 
gallic acid, 3 i — ij to gj [1-8 to 1-4] of ointment, kept in 
contact with the part for several days, acts as an escha- 
rotic. Multiple scarifications and the use of the galvano- 
cautery may be tried, but in many cases no form of 
treatment is successful. 

LUPUS VULGARIS. 

This disease, sometimes spoken of as lupus exedens, 
or noli-me-tangere, is a local tuberculosis of the skin. 

H 2 



186 Diseases of the Skin. 

It is due to the invasion of the cutaneous structures by 
the tubercle bacillus, which, acting as a source of irrita- 
tion, produces a cellular infiltration into the meshes of 
the connective tissue in the deeper portions of the 
corium. The cells are collected into small nodules, 
freety supplied with blood-vessels, and sharply marked 
off from other parts of the corium b} r firm connective 
tissue. In the course of many months or years, the 
whole depth of the skin may become invaded by the 
cell-growth. 

The disease manifests itself upon the skin by the 
formation of reddish or brownish patches, variable as 
to size and shape. The process begins by the develop- 
ment of small, pin-head-sized, soft, reddish papules, 
deeply seated in the skin, one or more in number, dis- 
crete or close together. These increase in size slowty 
and become tubercles, which coalesce, giving rise to 
patches. The patches enlarge by the appearance of 
new tubercles along the periphery. The further appear- 
ance of the disease depends upon the change which the 
lesions undergo. Sometimes the cellular deposit is 
absorbed, the skin returning to its normal condition. 
More frequently, however, fatty degeneration occurs, 
followed by ulceration and scarring. The ulcers are 
usually round, shallow excavations, with reddish granu- 
lations covering their bases ; the edges are soft. They 
bleed readily, and secrete a thin fluid, which dries into 
brownish crusts, beneath which the destructive tendency 
proceeds. The granulations sometimes take on exces- 
sive growth. The ulcers finally heal, with the forma- 
tion of scar-tissue, which may be white and soft ; but, 
when the scars cover a large extent of surface, they 
are contracted, irregular, hard, and uneven, and cause 
much disfigurement. 



New Formations of the Skin. 187 

Lupus vulgaris begins almost invariably in child- 
hood, generalty after the second year, and may appear 
at any time before puberty. It is seldom encountered 
after that period for the first time. It occurs more 
frequent lj' in females. It is a rare disease in this 
country. It involves the skin and mucous membranes, 
and may even spread to and cause destruction of car- 
tilage, but it never invades the bone. The usual situa- 
tion of the disease is about the regions of the nose and 
cheeks. When it has existed for an}^ length of time, 
all stages of the disease may be present, — papules, 
tubercles, ulcers, crusts, and scars. It is prone to 
extend from the alae of the nose and the lips to the 
mucous membranes of the nose and mouth. Other 
regions invaded are the ears, hands, feet, mucous mem- 
branes of the larynx and conjunctiva. 

The course of this disease is steadily progressive, 
lasting for years. It is exceedingly destructive to the 
tissues which it involves. Under treatment it can be 
favorably influenced, and sometimes cured. 

Diagnosis. — Lupus is to be differentiated from syphi- 
lis, epithelioma, lupus erythematosus, acne rosacea, and 
squamous eczema. Sj'philis, especially in its ulcerative 
stage, is most likely to be confused with lupus, but the 
course and history ©f the two affections are quite dif- 
ferent. Lupus vulgaris begins in childhood ; its lesions 
consist of papules, tubercles, ulcers, and scars, which 
last an indefinite period, slowly passing from one form 
to another. Syphilis is a disease of adult life. The 
lesions appear rapidly, and undergo change quickly. 
The ulcers of lupus are small, shallow, and covered with 
a thin, brownish crust. Syphilitic ulcers are deep, 
with rounded edges, and covered with thick, dirty, 
green crusts. The scars of lupus are hard and 



188 Diseases of the Skin. 

irregular, while the scars of syphilis are smooth and 
soft. 

Epithelioma differs from lupus. It begins usually 
after middle life. The epitheliomatous ulcer is single, 
painful, spreads along its edges, and also in depth, 
invading all tissues, even the bone. The edges are hard 
and everted, the base uneven, covered with red granu- 
lations, which bleed easily, and thin, brownish crusts 
form. 

Lupus erythematosus begins in adult life, and con- 
sists of red patches. The disease is symmetrical ; it 
is never attended by ulceration ; the surface of the 
patch is covered with scales ; the sebaceous follicles are 
enlarged. 

Acne rosacea sometimes bears a resemblance, but 
can be distinguished by the dilated vessels, acne pus- 
tules, and absence of ulceration. 

Squamous Eczema. — The length of time lupus has 
existed in a small area, its raised margins, and the 
absence of oozing distinguish it from this disease. 
Eczema changes from one form to another, and appears 
quickly. 

Treatment. — Attention should be paid to the general 
condition of the patient; to his diet; to his surround- 
ings. Good, nutritious food, alteratives, codliver-oil, 
iodide of potassium, iron. In most cases, local measures ' 
only are needed. These are employed for the removal 
of the diseased tissue. They consist of cauterization, 
scarification, erasion, and excision. The particular 
method to be employed depends upon the stage of the 
disease, the extent of surface, and the region involved. 
When only a small area is to be treated, or the lesions 
are discrete, caustics may be used. The solid stick of 
nitrate of silver is to be bored into the papules and 



New Formations of the Skin. 189 

tubercles. Upon the patches nitrate of silver may be 
used in solution. Pyrogallic acid, 1 or 2 drachms to 
the ounce of ointment [1-8 to 1-4], applied upon a 
piece of cloth for several days, will cause destruction 
of the diseased tissues. Arsenic is employed for the 
same purpose, but it is quite painful. The tissue is 
sometimes destroyed by the actual cautery or by the 
galvano-cautery, or it may be removed by the dermal 
curette, a sharp, spoon-shaped instrument, followed by 
the application of solid nitrate of silver or the pyro- 
gallic-acid ointment. Good results are obtained by 
this method. Multiple scarifications are also used. 
Hardaway has reported success with electrolysis. 
Treatment by Koch's Ivmph has proved a failure. 

AINHUM. 

A disease which occurs in the negro race, and is met 
with in the Southern States, in Africa, and in South 
America. It consists of a narrow, cord-like constric- 
tion, about the digito-plantar fold of the little toe, be- 
ginning on the inner and under surface. It spreads 
slowly, until, in the course of several years, a complete 
ring is formed. A deep furrow results, and in time the 
circulation is cut off, ulceration or gangrene is estab- 
lished, and the toe drops off. The distal portion of the 
toe swells up to two or three times its natural size. 
There is reason to believe that the constriction is pro- 
duced by tying a string around the toe. At first only 
itching is present ; later, however, there is intense pain. 
When seen early the process may be stopped by incising 
the band ; later, amputation is necessary. 

PODELCOMA. 

This disease is endemic in India, but is not limited 
to that country, a case having been reported in America. 



190 Diseases of the Skin. 

It attacks various regions of the body, though usually 
limited to the foot, and is sometimes described as the 
Madura foot, or fungous foot of India. It begins by a 
swelling of the part affected ; numerous soft, pea-sized 
tubercles form over it ; sinuses lead down to the deeper 
structures, and a discharge occurs, more or less glairy 
and containing blackish nodules compared to fish-roe. 

The disease progresses slowly; the destructive proc- 
ess involves all the tissues, muscles, fascia, and bone, 
until utter disintegration ensues. The foot becomes de- 
formed, and the patient is unable to walk on account of 
the severe pain. 

The nature of the disease is not known, but it is sup- 
posed to be of parasitic origin. When the process is 
not far advanced, removal of the diseased tissue is 
called for ; later, amputation is required. 

MYOMA. 

This is an exceedingly rare disease of the skin. It ex- 
ists as single or multiple disseminated tumors, consisting 
of smooth or unstriped muscular tissue. The multiple 
tumors, which are met with over the trunk and extremi- 
ties, varying in size from a pea to a bean, are flat, raised, 
round and oval, usually painful growths, freely movable 
and of a pale-red color. They occur generally late in life. 

The solitary tumors are more common and attain a 
larger size, usually that of a w r alnut; are sessile or pe- 
dunculated; not painful, as a rule; and are met with 
about the breast and genital organs. 

Sometimes there is considerable fibrous tissue mingled 
with the muscular fibres (fibro-n^oma), or blood-vessels 
may be highly developed (angio-myoma), and occasion- 
ally its lymphatics are involved (lymphangio-myoma). 

The tumors may be excised ; they do not recur. 



New Formations of the Skin. 191 

NEUROMA. 

There are bat few cases recorded of this extremely 
painful growth. It consists of small, multiple, pea- to 
hazel-nut- sized, flat, round, or tubercular nodules, which 
have their seat in the skin, but may extend into the 
subcutaneous tissue. They are immovable and painful 
on pressure. Painful sensations of a parox3'Smal nature 
occur and last for hours. They are found along the 
upper or lower extremities crowded closely together. 
They develop slowly over a period of many years. 
Their intimate structure is composed of fibrous tissue 
and non-medullated nerve-fibres. Excision of a portion 
of the nerve-trunk which supplies the region affected is 
followed sometimes by a cure, the tumors disappearing. 
At any rate, marked relief from pain is obtained. 

PERFORATING ULCER OF THE FOOT. 

This occurs as the result of pressure or injury to a 
part, of which the nervous supply is defective. It is 
thus seen in connection with locomotor ataxia, in which 
the spinal centres are at fault ; in syphilis and leprosy, 
in which deposits take place along the nerves; and in 
peripheral neuritis. The ulcer forms always on the sole 
of the foot, at the junction of the tarso-metatnrsal joints 
of the large or small toe, and consists of a small aper- 
ture, surrounded by thickened epidermis, leading down 
by a narrow sinus to diseased bone. There is no dis- 
charge from the ulcer, nor is pain connected with it. 
There may be more than one ulcer upon one or both 
feet. The affected foot perspires freely. 

Treatment. — The foot should be kept at rest, or 
suitable pads employed, so as to relieve the part from 
pressure. Amputation has been resorted to, but this is 
unsatisfactory, as ulcers form upon the stump. 



192 Diseases of the Skin. 

III. Vascular New Formations. 

^LYMPHANGIOMA. 

Lymphangioma appears in the form of one or more 
groups of deep-seated vesicles, upon a limited area of 
the skin. The vesicles are pin-head-sized and larger, with 
thick walls, which, when opened, discharge a clear, 
colorless fluid. They are colorless or of a pinkish line. 
The regions invaded are the face, neck, shoulders, and 
extremities. 

Another form, designated lymphangioma tuberosum 
multiplex, consists of numerous pea- to hazel-nut- sized 
tubercles, which involve the trunk uniformly. The}' are 
smooth, firm, elastic growths, of a brownish color, and 
under pressure can be made to disappear into the skin, 
but re-appear immediately. 

Lj'mphangioma is in many cases a congenital disease, 
or it may begin in early life. It pursues a slow, chronic 
course. Subjective sensations are absent. The affection 
is the result of the enlargement of the lymphatics in the 
skin. Cross-section of a nodule shows it to be made up 
of small cavities filled with a clear fluid. Treatment is 
of no avail. 

ANGIOMA. 

Angioma, or nsevus vascularis, is a congenital growth, 
consisting in the development of new and enlarged 
blood-vessels, situated in the skin or subcutaneous tis- 
sue. Two distinct forms are encountered, which depend 
upon the kind of blood-vessels involved. When the 
capillaries alone are dilated, usually a single patch exists ; 
but there may be several patches, varying in size from 
a pin-head to a bean, or as large as the palm. The\' are 
on a level with, or slightVv raised above, the surface of 
the skin ; of a bright- or dark- red or purplish color. 



Neic Formations of the Skin. 193 

round or irregular in shape, and soft to the touch. On 
pressure, the color fades away and quickly returns. 
The usual situations of these growths are about the 
head, especially the face and lips, the neck, and the 
arms. They may be quite small at first, and enlarge 
slowly, until, having attained a certain size, they cease 
to grow, and remain stationary throughout life. At 
times they disappear more or less complete^, leaving 
pale atrophic scars behind. The port-wine mark is a 
form of capillary nsevus. 

The other kind of vascular tumor depends upon the 
formation of enlarged veins, which begin in the sub- 
cutaneous tissue and subsequently may involve the 
skin. They occur, for the most part, about the lower 
region of the bocty, the back, and limbs, and consist of 
smooth or lobulated, prominent, erectile, sometimes 
pulsating growths, varying in size from a pea to a 
walnut and larger. They are soft and compressible. 
Nothing is known as to the cause of these formations. 
They should be distinguished without difficulty. 

Treatment. — When the naevi are small and not in 
conspicuous places, they may be left alone. Occurring 
about the cheeks, they give rise to much annoyance. 
Their removal may be effected, when small and of the 
capillary variety, in various ways. Vaccination is some- 
times followed by good results, a white scar taking the 
place of the enlarged vessels. Painting the patch with 
collodion or liquor plumbi subacetatis dailj 7 , for several 
weeks, will cause constriction of the capillaries. Caustic 
applications, such as strong nitric acid or caustic potash, 
1 to 4 drachms to the ounce of water, applied once or 
twice, may be of benefit, Multiple scarifications, the 
incisions being made parallel, close together, and cross- 
hatched, the object being to destroy the vessels, as well 

9 I 



194 Diseases of the Skin. 

as multiple puncture by many closely-placed needles, 
are recommended, but the results are not satisfactory. 
The best method at our disposal consists in the applica- 
tion of electrolysis, such as is employed for the removal 
of superfluous hairs. To the negative pole of the gal- 
vanic battery the electrolytic needle is attached, and is 
inserted into the growth, while to the positive pole is 
attached a sponge-electrode, and this is applied to any 
portion of the body. From ten to fifteen cells are em- 
ployed. The needle is retained for a few seconds. Even 
in large port-wine marks benefit is derived from such a 
procedure. 

In the more prominent nsevi the growth may be 
strangulated by the ligature. The galvano-cautery is 
also used to destroy the blood-vessels. 

TELANGIECTASIS. 

This consists in the enlargement of pre-existing 
blood-vessels and in the formation of new vessels. The 
disease is usually of spontaneous origin, and occurs 
during middle life. It shows itself upon the skin in the 
form of round or oval, pin-head to pea- sized, bright- or 
dark- red, or violaceous, level, or nfised patches, or as 
tortuous lines. There is usually a central bright-red, 
smooth spot, with fine, spreading capillaries, radiating 
in all directions. They occur in numbers here and 
there over the surface, but for the most part about the 
face and chest. They never attain to any great size, 
but pursue a chronic course, enlarging slowly. Some- 
times they disappear spontaneously. 

Rosacea is a form of telangiectasis which is met 
with about the face and nose, — as a more or less diffused, 
dull redness, or as a localized patch, with dilated, tortu- 
ous veins. It occurs associated with acne and sebor- 



New Formations of the Skin. 195 

rhoea, in those exposed to the inclement weather — as 
cabmen and sailors — and in those addicted to the use of 
alcohol. 

The treatment consists in the destruction of the 
blood-vessels by electrolysis. 



NEUROSES. 

(By J. Williams Lord, A.B., M.D.) 



In this group are classed various functional disturb- 
ances of the skin, consisting of disorders of sensibility, 
and comprising hyperesthesia, anaesthesia, dermatalgia, 
and pruritus. 

HYPERESTHESIA. 

This is a condition of increased sensibility of the 
skin. It may be idiopathic or symptomatic. It is 
usually secondary to some functional or organic disease 
of the nervous system. It ma}^ be localized or diffused, 
limited to one-half of the body, or extend over the entire 
surface. In many cases it is an expression of hysteria. 

ANESTHESIA. 

Anaesthesia implies a diminished or complete absence 
of sensibilit}^. This may be local or general, idiopathic 
or symptomatic ; the result of external causes or of 
internal conditions. Locally, it may be due to the 
application of cold and freezing mixtures, carbolic acid, 
cocaine, the essential oils, or to injury to nerves. It is 
secondary to deposits in the nerves, as in leprosy and 
syphilis. It occurs in hysteria and organic disease of 
the brain and cord; also from the administration of 
ether and chloroform. 

DERMATALGIA. 

Dermatalgia, or neuralgia of the skin, is an extremely 

painful condition, limited to a small area, and usually 

involving the hairy region. It is more frequent in 

women. There is no structural change in the affected 

(196) 



Neiwoses. 197 

part. The pain is intermittent, spontaneous, super- 
ficial, of a burning, darting, boring character, increased 
b}' pressure, and is worse at night. It may be the 
result of rheumatism, anaemia, and chlorosis, or of 
functional or organic disease of the nervous system, 
as listeria and locomotor ataxia. 

The treatment depends upon the cause. Relief may 
be obtained from blisters, the galvanic current, and, in 
cases of rheumatism, the salicylate of soda. 

PRURITUS. 

This is a functional disorder of the skin, not 
dependent upon any structural change, and is charac- 
terized by itching. It may be general or local. The 
itching varies in its intensity, is of a paroxysmal nature, 
and is worse at night, the patient being unable to resist 
the desire to scratch. In some cases, secondary changes, 
such as excoriations, papules, thickening of the skin, 
and pigmentation, arise, as the result of the scratching. 
In other cases there is no change in the skin, and only 
the patient's statement is to be relied upon. 

The regions involved are usually the perineum, anus, 
scrotum, and vulva ; but the face and scalp and other 
portions of the body may be implicated. It is com- 
monly encountered during middle life and in old 
age, but occurs sometimes in childhood. In many cases 
the cause of the affection is unknown. Varied con- 
ditions may call it forth, — gastric and intestinal dis- 
orders, haemorrhoids, jaundice, diabetes, pregnancy, 
leucorrhceal discharges, and seat-worms. 

Pruritus affects certain individuals during the winter 
only. Old age, with its accompanying atrophic change 
of the skin, is frequently attended by intense general 
itching. 



198 Diseases of the Skin. 

Treatment. — Remove all local sources of irritation 
and treat the general condition, which gives rise to 
pruritus. Constipation should be relieved b} r salines 
and mineral waters. The fluid extract of jaborandi, in 
fifteen-minim doses, and the tincture of cannabis Indica, 
in like doses, three times a daj^, occasionally give relief. 
Localty, lotions (Formulae 63, 64), ointments (Formulae 
65, 66, 68), or baths containing bran or soda may be 
used. 

When the pruritus depends upon a leucorrhceal dis- 
charge, astringent injections of alum, tannic acid, zinc 
sulphate, and the like should be employed. 



PARASITIC SKIN DISEASES. 

(By J. Williams Lord, A.B., M.D.) 



The parasitic skin diseases are divided into two 
classes, — those due to vegetable and those due to animal 
parasites. 

I. Vegetable Parasitic Skin Diseases. 

The commonly recognized vegetable parasitic skin 
diseases are favus, ringworm, and parasitic chloasma. 
They are generally grouped together under the generic 
term tinea, first applied to them by the late Dr. Tilbury 
Fox, and the individual diseases are technically known 
as tinea favosa (favus), tinea trichophytina (ringworm), 
and tinea versicolor (chloasma, or pityriasis versicolor). 

The organisms producing these diseases belong to 
the class Fungi, and are easily recognizable under a 
comparatively low power of the microscope (three 
hundred to five hundred diameters). 

Most pathologists, following the authority of the 
leading botanists in this field, regard the different 
organisms as separate species, although some derma- 
tologists and pathologists believe that the parasitic 
fungi found in skin diseases are merely stages of devel- 
opment of one or other of the common mold fungi so 
widely distributed in nature. 

This conclusion has, however, not been generally 
accepted, although receiving support from an observa- 
tion of Hebra, who produced a mixed eruption resem- 
bling ringworm and favus by the prolonged application 
of moist, moldy compresses to the skin. 

(199) 



200 Diseases of the Skin. 

TINEA FAVOSA. 

Favus is a contagious vegetable parasitic disease, 
which appears for the most part about the scalp, but may 
occur upon any portion of the bodj r . It begins as a 
slightly-reddened spot, soon becoming scaly. A pin- 
head-sized, yellow crust then forms about the opening of 
a hair-follicle, and increases to the size of a pea. It is dis- 
tinctly raised above the surface of the scalp, dry, sul- 
phur-yellow and umbilicated, usually penetrated by one 
or more hairs. When the crust is removed the under 
surface is seen to be convex, causing a corresponding 
depression in the scalp, which is reddened and moist- 
ened by a sticky, serous fluid or pus. These crusts appear 
in one or more places, or may involve the entire scalp and 
become confluent. The hair is dry, lustreless, and soon 
drops out, leaving pale, atrophic, bald patches. There is 
a peculiar, musty, mousy odor about the scalp. Favus 
crusts may appear upon the arms, legs, and the nails. 
Favus begins in childhood, and may last throughout 
life. It is exceeding^ chronic and rebellious to treat- 
ment. It is a rare disease in this country, most of the 
cases being brought here from Europe. It is favored 
by filth and lack of cleanliness. It is due to the invasion 
of the epidermis, hair, and hair-follicles, by the spores 
and mycelium of the fungus, the achorion Schoenleinii. 

Diagnosis is not difficult. When there is pus about 
the base of the crusts it may resemble a pustular eczema. 
In eczema the hair does not fall out. The crusts reveal, 
under the microscope, the peculiar fungus. 

Treatment. — Remove the crusts by soaking the 
scalp with sweet-oil, pull out the diseased hairs, and 
finally rub in a parasiticide, such as sulphur ointment, 
oil of cade, ointment of ammoniated mercury or car- 
bolic acid, and sulphurous acid. The latter may be ap- 



Parasitic Skin Diseases. 201 

plied to the diseased spots in full strength. The disease 
is usually very resistant. 

TINEA TRICHOPHYTINA. 

Tinea trichophytina, or ringworm, is a contagious, 
vegetable, parasitic disease, due to the trichophyton 
fungus. It appears upon the scalp, the bearded region, 
and the general body surface. It receives various 
names according to the regions invaded, on accojunt of 
the different clinical features. Upon the trunk it is 
known as tinea circinata ; upon the scalp, tinea ton- 
surans ; upon the bearded portion of the face, tinea 
sycosis. 

Tinea circinata begins by one or more slightly-red- 
dened spots about the face, neck, or chest, which enlarge 
with the formation of papules or vesicles along the 
periphery, while the centre of the patch clears up and 
becomes covered with grayish scales. The patch thus 
assumes a ring shape. Individual patches reach the 
size of a quarter to half a dollar; many coalesce, irregu- 
lar shapes arising. There are usually many patches, 
w r hich may spread over the whole body. Itching is 
slight. The disease is met with at all ages, though more 
commonly in childhood. 

Tinea circinata occurring about the axilla or in 
the fork of the thighs is somewhat modified. It pre- 
sents more inflammatory symptoms and resembles 
an eczema. It is described as an eczema marginatum. 
The growth of the fungus is favored here by the heat 
and moisture. The skin is reddened, markedly itchy, 
and more or less oozing is present. The whole of the 
upper portion of the thighs is involved. The margins 
of the patches are distinctly raised, sharply defined, 
and several smaller spots are seen along the borders. 

9* 



202 Diseases of the Skin. 

Tinea tonsurans begins as an ordinary patch of ring- 
worm, a small, red, scaty, round spot, which enlarges 
slowty. The hair soon becomes diy, lustreless and 
brittle, and breaks off close to the scalp, giving the 
patch a stubbly appearance. One or more patches may 
be present. It occurs only in childhood. When the 
suppuration extends deeply into the scalp and a boggy 
elevation is produced, it is known as kerion. 

Tinea sycosis may involve a limited area or more or 
less of the entire bearded region. It rarely attacks the 
upper lip. It is conveyed by the razor from one person 
to another, and is commonly known as the barber's 
itch. It begins as a small, red spot, but soon the hair 
and hair-follicles are invaded by the fungus, giving rise 
to inflammation of the subcutaneous tissue, and a hard, 
nodular, lumpy formation results ; pustules develop 
about the hairs, and a glairj^, muco-purulent discharge 
takes place, which dries into crusts. It is a disease of 
adult life and of the male sex. 

All varieties of ringworm are contagious. 

Diagnosis. — Ringworm of the body is to be differ- 
entiated from psoriasis, the annular syphilide, and 
seborrhoea. 

In psoriasis the patches are of a brighter red, and 
the scales much more abundant and glistening. The 
patches are symmetrical. 

In the annular syphilide the margins are indurated, 
of a coppery color. Other symptoms of 'syphilis are 
usually present. 

In seborrhoea the patches are small, the edges fade 
away gradually, and the scales are greasy. 

Ringworm of the scalp resembles, at times, an 
alopecia areata and a scaly eczema. 

In alopecia areata the bald patches are smooth. In 



Parasitic Skin Diseases. 203 

ringworm the patch is covered witJi scales and stubbly 
hair. 

In scaly eczema the scalp is reddened, infiltrated, 
the hair is not diseased, and there is a history of moisture 
at one time in the course of the disease. 

Ringworm of the beard must not be mistaken for a 
pustular eczema or simple sycosis. 

Eczema pustulosum occurs usually in childhood. 
The pustules are grouped, small, and not limited to 
the hair-follicles ; the skin beneath is red and moist ; no 
nodules. 

Sycosis non-parasitica consists of small, pin head 
pustules about the hair. It is met with most fre- 
quentty along the upper lip. There is no nodular 
formation. 

Treatment. — Tinea circinata readily responds to 
treatment. Tinea sycosis, tinea tonsurans, and kerion 
are more difficult to overcome. In all forms, the 
parts should be washed with sapo viridis. In tinea 
sycosis and tinea tonsurans this should be followed by 
epilation, and then the use of a parasiticide. Bichloride 
of mercury, 2 grains to the ounce [1 to 250] of water 
or alcohol ; white-precipitate ointment, -| to 1 drachm 
to the ounce [1-16 to 1-8] ; oleate of mercury, 5- to 
15-per-cent. strength ; sulphur ointment ; oil of cade, 1 
to 2 drachms to the ounce [1-8 to 1-4], may all be used 
with success. 

Care must be taken to avoid producing too much 
irritation by the remedies employed. 

TINEA VERSICOLOR. 

Tinea versicolor is a vegetable parasitic disease, clue 
to the microsporon furfur. It begins by pin-head to 
pea- sized, yellowish spots, scattered over the surface. 



204 Diseases of the Skin. 

These gradually enlarge, coalesce, and form irregularly 
shaped patches of a light- or dark- yellow or even black 
color. The edges of the patches are sharply defined, 
and the surface is somewhat scalj r . Itching may be 
present, but it is often absent. In delicate skins and in 
those who perspire freely the patches are hyperamiic. 

The regions invaded are the front of the chest, neck, 
back, abdomen, arms, and flexor surfaces of the elbows; 
the face, hands, and feet escape. It is but slightly con- 
tagious. It occurs only in adults and in those who 
perspire freely, and is frequently seen in phthisical sub- 
jects. It is essentially chronic in its course, and may 
last for y ears. 

The fungus grows in the upper layers of the epider- 
mis, and consists of a mycelium and spores. It can be 
readily detected by the aid of the microscope. Remove 
a little of the scale, and moisten with caustic potash ; 
examine under a power of 500 diameters. The spores 
appear in groups. 

The diagnosis can be easily- made by paying atten- 
tion to the region involved, the color, and the scales. 
If in doubt, examine by the microscope. It must not 
be mistaken for the macular sj^philide. In syphilis, in 
addition to the eruption, there are other sj'mptoms of 
the disease. The eruption comes out suddenly, and 
appears not only on the trunk, but the face, arms, and 
legs. 

Chloasma is a pigmentary affection, and occurs in 
patches upon the face and hands, and not upon the 
body. There are no scales, but merely an increase in 
the amount of pigment. 

Treatment. — Simple, mild parasiticides, such as the 
sulphite or hyposulphite of sodium, in lotion or oint- 
ment, a drachm to the ounce [1 to 8]. Sulphurous acid, 



Parasitic Skin Diseases. 205 

pure or diluted, will usually be effectual. The remedy 
must be continued for some time after all manifestations 
of the disease have disappeared ; otherwise, some of the 
spores of the fungus, preserved between the epithelial 
scales, may take on renewed growth and develop into 
the mature parasite again. 

II. Animal Parasitic Skin Diseases. 

The skin diseases due to animal parasites are scabies 
and pediculosis. 

SCABIES. 

The invasion of the skin by an animal parasite — the 
sarcoptes scabiei — gives rise to certain inflammatory 
symptoms, and to a distinct lesion — a burrow — which is 
characteristic. The female acarus, after impregnation, 
penetrates the epidermis, boring its way down to the 
mucous layer, depositing its eggs as it advances. These 
vary from a dozen to fifty in number. In the course of 
a week or fortnight the eggs hatch out. 

The burrow, or cuniculus, consists of a slight eleva- 
tion of the epidermis, from a quarter to half an inch in 
length, straight, tortuous or zigzag, colorless or marked 
by black dots. The parasite selects the thinnest por- 
tions of the skin. The lesions appear first about the 
web of the fingers, the flexor surfaces of the wrists, then 
the axillae, under the mammae, around the umbilicus, 
upon the penis, and the front of the thighs. The face 
and neck escape, except in babies. Itching is intense, 
especially at night ; and the patient, in order to obtain 
relief, tears the skin by his scratching, and secondary 
symptoms are produced. These consist of torn papules 
and vesicles, blood-crusts, excoriations, pustules, and 
even blebs, and a more or less inflammatory swelling. 



206 Diseases of the Skin. 

In those predisposed to eczema such a condition fre- 
quently becomes a complication. 

Scabies pursues a steadily progressive course, and 
lasts indefinitely, unless the cause is removed. It is 
more frequent in European countries than in America. 
Here it forms about 2 per cent, of skin diseases. 

Diagnosis. — Scabies is to be differentiated from an 
eczema and from pediculosis. The presence of the 
cuniculus is diagnostic. It should be looked for be- 
tween the fingers. Upon other parts of the body it is 
soon lost, — from the scratching. The regions invaded 
are characteristic. The history of contagion is also of 
aid. In eczema the vesicles and pustules tend to group, 
and are not scattered in an irregular manner as in 
scabies ; nor are the same regions invaded. In pedicu- 
losis the lesions are confined to those parts of the body 
covered b3^ the clothing. 

Treatment. — The patient should first be given a 
warm bath, with plenty of soap, and thoroughly 
scrubbed; afterward, a parasiticide is to be rubbed 
in. Sulphur, 1 to 2 drachms to the ounce of ointment 
[1-8 to 1-4] ; balsam of Peru, — painted on with a stiff 
brush. The applications should be made twice a day 
for three da} T s, followed by a bath. If, in the course of 
a few days, the itching continues, repeat the treatment. 
Scabies, as seen in this country, usually responds 
readily to the applications mentioned. 

PEDICULOSIS. 

There are three kinds of lice which infest the human 
body, — the pediculus capitis, or head-louse ; the pedicu- 
lus corporis, or bod} r -louse, and the pediculus pubis, or 
crab-louse. 

The body-louse lives in the clothes, and goes to the 



Parasitic Skin Diseases. 20T 

body only to obtain nourishment; the other varieties 
live upon the body. By means of a sucking apparatus, 
which they insert within a hair-follicle, the}' obtain the 
blood, which serves as a food. This act gives rise to 
a hemorrhagic spot, with a slightly-reddened areola 
about it. Other lesions are always present, but these 
are due to the scratching, and consist of scratch- 
marks, wheals, pustules, thickening of the skin, and 
pigmentation. 

Pediculosis Capitis, due to the pedi cuius capitis, is 
to be found upon the scalp, usually over the occipital 
region, mostly in children. The little insects can be 
seen running over the hairs. They deposit their eggs 
or nits along the hair. The nits are small, pear-shaped, 
grayish in color. More or less eczema is invariably 
present, the scalp in patches being reddened and covered 
with pustules; the hair becomes matted, crusts form; 
the glands at the back of the neck enlarge, sometimes 
suppurate, and abscesses develop. 

Treatment. — The scalp should be rubbed with crude 
petroleum twice a day, for two or three days ; this 
destroys both the lice and the nits. Tincture of coccu- 
lus Indicus also gives good results. 

Pediculosis Corporis is due to the body-louse. The 
characteristic lesion consists of a minute hemorrhagic 
spot; other symptoms are alwaj^s present, the. result of 
scratching. Body-lice are found upon old and unclean 
persons. The lice live in the clothes, and deposit their 
eggs in the seams. The lesions occur mostly about the 
neck and shoulders. 

Treatment. — The clothes should be thoroughly 
baked. The patient is to receive a bath ; afterward, a, 
sulphur ointment or petroleum is to be rubbed into the 
skin. 



208 Diseases of the Skin. 

Pediculosis Pubis is due to the pediculus pubis. 
There is itching, and inflammatory lesions are also 
present. The lice firmly adhere to the hair near the 
root. They are found about the pubis, sometimes in 
the axillae, and occasionally about the eyelashes. 

Treatment. — A few applications of mercurial oint- 
ment are sufficient. 



THE CUTANEOUS MANIFESTATIONS 
OF SYPHILIS. 



General Considerations. 

Syphilis is a chronic infectious disease of the 
system, which, in the course of its evolution and devel- 
opment,, produces characteristic s} r mptoms and lesions 
in various organs and tissues of the bod} r . The follow- 
ing pages will be devoted to the consideration of one 
class of these morbid changes, namely, those involving 
the general integument and its appendages. 

The cutaneous manifestations of syphilis were 
recognized by the earliest writers upon venereal dis- 
eases. Thus, Leonicenus (1497), Gaspard Torella 
(1498), Peter Pintor (1500), Griinpeck (1503), John de 
Yigo (1514), and others describe the eruptions with 
more or less accuracy. On account of their promi- 
nence, these lesions have always commanded a large 
share of the attention of sj^philographers, as well as of 
the general profession and the laity. 

The s} T philitic skin diseases may be properly regarded 
as the first evidences of the constitutional effects of the 
venereal infection. The chancre and enlarged lymphatic 
glands are more or less local manifestations of the 
virus due to direct irritation. When, however, the 
period of general eruption, with its accompanying fever, 
has declared itself, the poison has reached the blood, 
which fluid then becomes itself infective, and may com- 
municate the disease if inoculated. 

12 (209) 



210 Diseases of the Skin. 

GENERAL MORPHOLOGY AND CLASSIFICATION OF SYPHILITIC 
SKIN DISEASES. 

The general features of the cutaneous lesions due to 
syphilis resemble more or less closely those of the 
ordinary skin diseases. For this reason most of the 
older and, indeed, many modern writers on syphilis 
adopt the ordinary derinatological nomenclature to 
describe S3 T philitic skin diseases, using the adjective 
" syphilitic " as a differential designation. Hence, one 
meets frequently, in medical writings, such compound 
names as " syphilitic roseola," " syphilitic acne," 
" syphilitic lupus," u syphilitic pemphigus," and even 
" syphilitic eczema." If it is borne in mind that acne, 
lupus, pemphigus, and eczema on the one hand, and syphi- 
lis on the other, are perfectly distinct morbid processes, 
having nothing in common, and that the name S3 T phi- 
litic lupus is not intended to conve}^ the impression of 
a mixed disease, partly S3 T philis and partly lupus, or 
even a lupus occurring in a syphilitic subject, but that 
it means simply a lupus-like syphilitic lesion, it is plain 
that such a terminology leaves much to be desired on 
the score of clearness and simplicity. The first de- 
parture from this unphilosophical and confusing nomen- 
clature was made by Biett 1 (1829), who classified the 
sy^philitic skin diseases according to their elementary 
lesion. The classification of Biett, modified in some 
unimportant particulars, is the one adopted by most 
syphilographers at the present day. 

Alibert (1838) 2 introduced the collective term 
" syphilide " to characterize the cutaneous manifesta- 
tions of the venereal disease. Inasmuch as all sj-philitic 

1 Practical Synopsis of Cutaneous Diseases. Cazenave and Schedel. 
Philadelphia, 1829, p. 337. 

a Nosologie Naturelle. Paris, 1838. 



The C utaneous Manifestations of Syphilis. 211 

eruptions are primarily dependent upon the presence 
of the syphilitic virus in the blood or tissues, no objec- 
tion can be urged against using this term as a sub- 
stantive term and defining the different lesions by 
adding the proper adjective. 

Syphilis of the skin manifests itself under the ele- 
mentary forms of hypersemic discoloration s, papules, 
pustules, tubercles, and nodules ; and as secondary or 
consecutive lesions, namely, ulcers and pigmentations. 
A simple classification of the syphilides would, there- 
fore, be as follows : — 

1. The erythematous syphilide. 

2. The papular syphilide. 

3. The pustular syphilide. 

4. The tubercular syphilide. 

5. The nodular syphilide. 

As consecutive lesions or processes may be added — 

1. The ulcerating syphilide. 

2. The pigmentary syphilide. 

GENERAL DIAGNOSTIC FEATURES OF THE SYPHILIDES. 

The diagnosis of syphilitic eruptions should offer 
little difficulty, if the definitions of the elementary 
lesions are clearly appreciated and borne in mind. 
There are, however, some general characters of the 
syphilides a knowledge of which mny render their 
recognition still more easy. Among the more impor- 
tant of these characters are the following : — 

CHRONOLOGICAL SEQUENCE AND COURSE OF ERUPTIONS. 

Clinical observation has taught that the syphilides 
follow each other in a certain consecutive order. Thus, 
those lesions affecting principally the superficial layers 
of the skin occur early, while those extending more 



212 Diseases of the Skin. 

deeply follow later. For example, the first manifesta- 
tion of constitutional infection is usually the erythema- 
tous syphilide, which may be succeeded in turn by the 
papular, pustular, tubercular, and nodular or gummatous 
forms. Ricord was the first who divided sj^philides 
into two classes, — the early (syphilides praecoces) and 
the late (syphilides tardives). The first class, consisting 
of eiTthematous, papular, and pustular, belonged to the 
secondaiy period, while the other consisted of manifesta- 
tions of the tertiary stage. This eminent syphilographer 
further laid it down as a law that the period of eruption 
of the S3 r philides is never reversed. Thus, an erythem- 
atous syphilide never follows a papular eruption, 
although the erythematous form may at times not 
appear, or perhaps be overlooked. This rule appears to 
have no exceptions for any individual attack of syphilis, 
but Zeissl 1 has pointed out that, in case of re-infection, 
the evolutionary C} T cle of the disease may be repeated, 
and one individual may, in his life-time, have an ery- 
thematous following a papular syphilide, but this could 
not occur during the same attack of syphilis. 

The careful stud}^ given to all features of the disease 
has shown that the division of the syphilitic eruptions 
into early and late, as made by Ricord, is only tenable 
in a general sense. Cases not infrequently occur in 
which some of the later manifestations (tubercles and 
gummata) are developed almost contemporaneously with 
the earlier eruptions, — such as papules and pustules. 

Reckoning from the period of primary infection or 
inoculation, the first development of the cutaneous 
lesions may be fixed at from nine to twelve weeks. 
The different eruptions succeed each other in crops, 
with periods of rest between the successive eruptions, 

1 Lehrbuck der Syphilis, Bd. ii,'3te Aufl, 1875, p. 103. 



The Cutaneous Manifestations of Syphilis. 213 

until what is usually known as the secondary period has 
been brought to a close. This generally coincides with 
the disappearance of the pustular syphilide. After an 
interval of ver}' variable duration, during which no 
manifestations of the disease may be present, the tertiary 
stage, so called, characterized by the eruption of the 
neoplastic syphilides, namely, tubercles, gummata, and 
their consequences, begins. Neither the duration of the 
secondary stage, the interval of latency, nor the tertiary 
stage can be given with any approach to correctness. 
The secondaiy stage is, however, brought to a conclu- 
sion, usually, within a year from the first appearance of 
the erythematous exanthem, especially if the patient 
has been subjected to appropriate treatment. The in- 
terval between the secondary and tertiary periods is 
usually several years, although the latent period may be 
entirely skipped, the secondary stage passing directly 
into the tertiary. 

In the secondary stage, or period of the precocious 
syphilides, the eruption is usualty symmetrical and the 
lesions profuse, the blood, pus, and possibly some of the 
normal secretions, infectious and inoculable. In the 
late, or gummatous stage, on the other hand, the lesions 
are few r , not symmetrically distributed, and the blood 
and secretions have lost their infectivity. In fact, 
according to some observers, the disease — syphilis — has 
disappeared, and the morbid manifestations are merely 
relics of a preceding pathological process. 

LOCALIZATION AND DISTRIBUTION OF THE SYPHILIDES. 

As just stated, the earlier syphilides are symmetrical, 
and with lesions profusely distributed. The prevailing 
localities for the eruptions are the trunk, the proximal 
portions of the extremities, the scalp, the border of the 



214 Diseases of the Skin, 

capillary growth on the forehead and nape of the neck, 
and certain portions of the face, especially the angles 
of the month and alae of the nose. The flexor surfaces 
are more prone to the eruption than the extensor ; and 
the palms of the hands and soles of the feet, which are 
usually spared in non-syphilitic affections of the skin, 
are especially liable to syphilitic eruptions, — more par- 
ticularly, the papular and squamous varieties. In local- 
ities where two surfaces of the skin are much in contact 
— as between the buttocks, the perineum, the axillae, be- 
tween the chest and pendulous breast in women — the 
papular syphilide, especially that form known as the 
moist papule or condyloma latum, has its site of predi- 
lection. Pustular syphilides are most frequently found 
affecting the hairy regions of the body, while the site of 
predilection of some of the later forms, such as subcu- 
taneous gummata, is found in the thighs, and especially 
the upper half of the leg. 

COLOR OF SYPHILITIC ERUPTIONS. 

In the text-books and standard works upon syphilis 
much stress is laid upon the color of syphilitic erup- 
tions. But the simple statement ordinarily made that the 
syphilides have a " raw-ham " color, or " copper " color 
is not sufficiently descriptive, for cases frequently occur 
to which neither of these characterizations apply. While 
the syphilitic coloration is nearly alwa}^s some shade of 
brown, the depth of tint varies considerably with the age 
of the lesion of which it is a part. Fournier speaks of " a 
sombre-red tint, a brown red, exactly identical with the 
hue of a slice of lean ham," and of " a tint not so dark, of 
red mingled with yellow, very happily compared by Swe- 
diaur to the color of copper." x Fournier states that the 

x Lemons sur la Syphilis. Paris, 1873. 



The Cutaneous Manifestations of Syphilis. 215 

color recalls to the e} T e " the tint of the old kitchen 
utensils, well polished, carefully kept" But other au- 
thors, among whom are Zeissl 1 and Griinfeld, 2 compared 
it, also after Swedianr, to tarnished copper. Swediaur 
himself, however, speaks of " spots of a reddish purple, 
yellowish, or livid color," and of "brown or copper- 
colored spots, 7 ' and again of " dark, copper-colored 
spots," 3 thus leaving it, in a measure, uncertain whether 
he meant polished or tarnished copper. 

Any one who makes a personal study of his cases 
will soon come to the conclusion that neither raw ham 
nor copper is a good standard for comparison with the 
color of syphilitic eruptions. The lesions may vary 
from a dull yellowish to dark brown, but one soon learns 
to recognize a peculiar quality in the tint which is quite 
characteristic, but not easily described, and which seems 
also to have eluded the artists who have made portraits 
of cases. 

The color of a syphilitic lesion of the skin is not due 
simply to local hyperemia, since it does not entirely 
disappear under pressure. There is, in addition to the 
inflammatory redness, an extravasation of blood-pigment 
to which the darker shade of coloration is due. Kaposi 4 
intimates that the specific diathesis may have some part 
in the production of discoloration. Cornil 5 sa} T s that 
" this coloration is owing particularly to extravasations 
of red blood-corpuscles ; as the spots are disappearing 
they become yellow, greenish-yellow, gray, following the 
tints of blood-pigment in a superficial eccli3 T mosis." 

1 Op. cit., p. 96. 

2 Eulenberg's Realencyclopadie, Bd. xiii, p. 304. 

3 Complete Treatise on Syphilis. Translated from the fourth French 
edition. Philadelphia, 1815. 

4 Syphilis. Stuttgart, 1881, p. 129. 

8 Syphilis. Philadelphia, 1882, p. 129. 



216 Diseases of the Skin. 

But this is not peculiar to syphilides, as in various non- 
specific cutaneous affections similar pigmentary changes 
may occur. However, when all is said, one may often 
derive some assistance in diagnosis by carefully observ- 
ing the color of the eruption and comparing this S} T mp- 
tom with others. The physician who relies upon the 
color of the lesion alone, to the exclusion of other 
symptoms, will frequently make mistakes. 

MULTIFORMITY OF LESIONS. 

Although it has been before stated that the S} T philides 
are characterized by a more or less uniform sequence of 
eruption, it is frequently the case that more than one 
form of lesion is present at the same time. Thus ery- 
thematous, papular, pustular, and tubercular lesions 
may all co-exist, or the eruption may consist of one 
variet} 7 of lesion, but in different stages of development. 
This is due to the chronic course of the syphilides, and, 
although some cases of eczema present a similar multi- 
formity of lesions, the clinical history of the two dis- 
eases is so different that they are not liable to be 
confounded with one another. 

CONFIGURATION OF THE ERUPTION. 

Most of the syphilides tend to assume an annular or 
crescentic arrangement. A group of papules, pustules, 
or tubercles is usually found to form either a complete 
circle, crescent, or curved line. This is especially 
well shown on the forehead, the nape of the neck, or the 
lower part of the face. In large flat tubercles the ab- 
sorption begins in the centre of the lesion, and after in- 
volution has progressed somewhat a circular ridge 
remains, which gradually disappears by an extension 
of the absorption from within. 



The Cutaneous Manifestations of Syphilis. 21? 

But this configuration is as little specific as the other 
peculiarities already mentioned. Ringworm, some cases 
of lupus, and annular erythema show the same arrange- 
ment of lesions. Hence, too much reliance must not be 
placed upon these S3'mptoins when taken singly. 

SUBJECTIVE SYMPTOMS. 

Itching, pain, or burning are. nearly always absent 
during the development of the earlier forms of syphilitic 
eruptions. In this absence of subjective symptoms a 
valuable aid to diagnosis is given to the physician. It 
must not be forgotten, however, that some non-specific 
eruptions which present a marked similarity to certain 
syphilides are frequently devoid of subjective symp- 
toms. On the other hand, syphilides sometimes itch, 
especially in persons with a delicate and irritable skin, 
and some gummata are exquisitely painful. 

RACIAL PECULIARITIES. 

Livingstone has stated that the negroes of the 
interior of Africa are exempt from the ravages of syphi- 
lis even after abundant opportunities for infection. 
Although it is frequent among the natives inhabiting 
the west coast, he sa} r s, " It seems incapable of perma- 
nence in any form, in persons of pure African blood, 
anywhere in the centre of the country. In persons of 
mixed blood it is otherwise ; and the virulence of the 
secondary symptoms seemed to be, in all cases that 
came into my care, in exact proportion to the greater 
or less amount of European blood in the patient." 1 In 
the United States, opportunities for observation upon 
persons of unmixed negro blood are becoming rarer 
every year ; but physicians of much experience in the 

1 Travels. London, 1857. 
10 K 



218 Diseases of the Shin. 

South will, doubtless, agree that the colored race suffers 
much more severely from syphilis than the white. 

In colored individuals, syphilis of the skin presents 
certain peculiarities which call for notice in this place. 
Few observations bearing upon this point are on record. 
The most thorough study of the effects of syphilis in 
the negro is contained in a paper by Dr. I. E. Atkinson, 
of Baltimore. 1 From an analysis of one hundred cases 
of the disease in the colored race, it appears that the 
predominant character impressed upon syphilis in the 
negro is a pronounced tendency to suppuration. The 
primary lesion is more destructive, the adenopathj" is 
more extensive, and the glands, in a very much larger 
proportion of cases than in whites, break down and 
suppurate, and all eruptions except the eiythematous 
showed a marked proclivity to become pustular. Ery- 
thema is difficult of recognition in the darker patients. 
The small papular syphilide is liable to be mistaken for 
keratosis pilaris. Attention has also been directed to 
this possible error by Duhring. The summits of the 
papules, when not pustular, often have a whitish colora- 
tion, partly due to an accumulation of fine scales, and 
partly to a more rapid exfoliation of epithelium. The 
pustular syphilide not infrequently presents a close re- 
semblance to cases of small-pox, as in two cases who 
presented themselves in my clinic not very long ago. 

It is hardly necessary to call attention to the fact 
that the " raw-ham " or " copper " color is of no value 
as a diagnostic sign in s} T philitic eruptions occurring in 
the colored race. 

Recapitulation. 

The syphilides are the first manifestations of general 

S} T stemic infection. 

1 Early Syphilis in the Negro. Md. Med. Journal, vol. i, 1877, p. 135 
et seq. 



The Cutaneous Manifestations of Syphilis, 219 

Syphilitic eruptions are either erythematous, papu- 
lar, pustular, tubercular, or nodular, or some mixed 
forms, modifications, or consequences of these elementary 
lesions. 

The syphilides follow a regular sequence in their 
eruption. The pustular or tubercular forms never pre- 
cede the erythematous. The earlier forms are usually 
superficial, while those coming later involve the skin 
more deeply. 

The average period of incubation of the primary 
lesion is three weeks ; from the appearance of this lesion 
to the outbreak of the first syphilides, six to ten weeks ; 
and the tertiary manifestations are rarely encountered 
until after a year from the date of infection. 

During the secondary period the blood and patho- 
logical secretions are infective. After the development 
of the tertiary or gummatous stage the infectivity of 
the blood and tissues has disappeared. 

The early sj'philides are symmetrical, and often pro- 
fusely distributed. The later forms occur singly, and 
show no tendency to S3 r mmetrical arrangement. The 
flexor surfaces are more liable to be the site of lesions. 

The color of the syphilides is usually a reddish or 
yellowish brown, described by authors as the " raw-ham " 
or " copper " color. This color does not disappear on 
pressure, being partly due to extravasation of blood- 
pigment into the tissues. 

The lesions are usually multiform, a pure example 
of papular, pustular, or tubercular syphilide being 
seldom seen. Syphilides are frequently aggregated in 
circular or crescentic groups. This is, however, not a 
characteristic symptom. Subjective symptoms, as itch- 
ing, burning, and pain, are usually absent in syphilitic 
eruption. 



220 Diseases of the Skin, 

In the negro race as met with in this country, syphi- 
lis shows a pronounced proclivity to the development 
of suppurative lesions and glandular enlargements. In 
this race the color of the eruption is of no aid in 
diagnosis. 

In order to make an exact diagnosis of a syphilitic 
eruption, the physician must have some knowledge of 
dermatology, be a good observer, and be able to group 
important symptoms in their proper relations and bring 
them into connection with the whole clinical history, 
objective and subjective, present and past, of the case 
under examination. 

The Erythematous Syphilide. 

[Synonyms. — Roseola syphilitica, macula syphilitica, 

erythema syphilitica, syphilis cutanea maculosa, pustule 
ortiee on formiculaire, macular s}-philide.] 

The erythematous syphilide is usuall}^ the first mani- 
festation of S3 T stemic infection by the S}^philitic virus. 
Its significance as a symptom of syphilis was recog- 
nized by the earliest writers upon the disease. Mention 
is first made of it by Torella (149?), followed b} T Mat- 
tioli (1535), Ferrier (1553), and Fernel * about the same 
time. During the seventeenth or eighteenth centuries 
little attention was paid to this manifestation of syphi- 
lis, and it was not until Ra^yer's master^ description 
(1827) that modern syphilographers appreciated the 
importance of this symptom in the clinical history of 
the disease. 

1 Kernel (1554) give3 this exact description of the erythematous syphi- 
lide : "Altera species paullo deterior est qua cutis universa crebris 
maculis minirne extuberantibus conspergitur usque parvis, lentigines 
instar, ac modo rubris, modo flavis, quae nOn ante deleri extiuguive pos- 
sunt, quam morbi radix sit evulsa . . . quam nulla graviora sequuntur 
incommoda." 



The Cutaneous Manifestations of Syphilis. 221 

The eruption appears in the form of roundish, oval, 
or irregular spots, of a pinkish, livid, or brownish-red 
color. They vary in size from one-half to two centi- 
metres (one-fourth to one inch) in diameter. At times 
they begin as red points, which rapidly enlarge until 
they have attained the size mentioned. Usually the 
spots are not elevated above the level of the surround- 
ing skin, although in some cases the affected skin is 
slightly tumid, while in others the centre of the spot 
is occupied by a small papule. The margins of the 
lesions are pretty clearly outlined. Underpressure of 
the finger the color may entirely disappear at first, but 
after the eruption has been out some time more or less 
pigmentation remains when the finger is passed over 
the spots. The color is more or less uniform, but 
usually a shade darker at the centre. The patches are 
not scal}\ Contrary to the ordinary erythemata, which 
become more marked when the temperature of the body 
is elevated, in the erythematous sypkilide cooling the 
surface brings out the eruption more prominently. 

The lesions are most freelv distributed on the lateral 
surfaces of the trunk, the back, abdomen, and the flexor 
surfaces of the extremities. The face is usually exempt. 
The skin over the sternum is, likewise, rarely the site of 
the erythematous syphilide. The penis and scrotum in 
the male, or the pudendal region in the female, are also 
exempt, except in cases to be presently referred to. 
The hairy margin of the scalp, palms of the hands, and 
soles of the feet are frequently attacked, but the dorsal 
surfaces of the hands and feet are nearly always free 
from the eruption. In negroes the erythematous S} T ph- 
ilide can rarely be recognized. 

The eruption is usually abundantly distributed, being 
sometimes scattered over the entire surface. When the 



222 Diseases of the Skin. 

lesions are few in number, they are almost altogether 
localized on the sides of the trunk and back. The 
creseentie or annular form is sometimes assumed on the 
forehead. 

The development of the eruption is usually slow, 
coming out in the course of one to two weeks. At 
times, however, the eruption is acute, the entire surface 
becoming covered in twenty -four to forty-eight hours. 
This is only liable to occur in persons of run-down con- 
stitutions. The case may be looked upon as an indica- 
tion of a severe attack of syphilis. In some cases the 
eruption occurs in successive crops, one crop fading as 
another appears. 

When the eruption reaches its height, it may main- 
tain its color and extent of distribution for a week or 
ten da} 7 s, and then begin to fade, the color passing 
through the varying shades of brownish-red to livid- or 
grayish-red, and finally disappear, leaving a slight yel- 
lowish-brown or grayish pigmentation, which often 
remains for a long time. The duration of the stage of 
involution A^aries from a few days to weeks and months. 
The longer the eruption remains, the deeper will be the 
remaining pigmentation. Where it lasts only a short 
time, there often remains no evidence of its previous 
existence. This, doubtless, accounts for many cases in 
which the eruption is not noticed. 

During acute febrile diseases, such as pneumonia, 
t} T phoid fever, etc., the eruption may disappear, to recur 
when the fever is at an end. 

The individual lesions alwa}^s remain distinct, never 
becoming confluent, as in some non-specific erythemata. 

Fournier 1 describes a variet} T of the erythematous 
syphilide under the name of roseola urticata. It is the 

1 Loc. cit. 



The Cutaneous Manifest ations of Syphilis. 223 

same as that named pustule ortiee by Alibert. This 
lesion resembles, in all respects, the simple erythematous 
syphilide, except that it is very slightly elevated above 
the surface of the surrounding skin. I have already 
referred to it above, and do not regard it of sufficient 
importance to demand description as a separate variety. 

In subjects who have undergone treatment for syph- 
ilis, the erythematous s^-pliilide sometimes recurs months 
after the disappearance of the first eruption. Foamier 
states that the date of recurrence may be postponed two 
or three 3' ears. It appears in very sparsely dissem- 
inated red or pink, flat or very slightly raised annular 
spots or patches. These may acquire a size of two to 
five centimetres (one-half to two inches) in diameter. 
They are especially liable to occur about the forehead, 
the abdomen, the lower part of the chest, and the glans 
penis. This form relapses with great readiness, and is 
sometimes exceedingly resistant to treatment. 

The skin of the genitals is rarely the seat of the 
erythematous syphilide, as already stated, but the glans 
and internal preputial surface, or the vulva, may be 
attacked, especially by the recurrent form. If there is 
vulvitis, balanitis, or a profuse seborrhoea of the glans 
present, the secretion rapidly decomposes and causes 
circumscribed erosions, which correspond to the ery- 
thematous spots. These erosions not rarely look like 
superficial chancres, and may give rise to false diagnoses. 
Practically, however, the result, so far as the danger of 
infection is concerned, is the same, as the secretion from 
these erosions is infectious, and may convey sj'pbilis 
during venereal intercourse. 

The erythematous syphilide may disappear com- 
plete^, after a varying duration, leaving a normal- 
colored skin, or pigmented spots, to mark the eruption. 



224 Diseases of the Skin. 

In some cases, the papular and pustular manifestations 
may make their appearance before the erythematous 
spots have disappeared. 

CONCURRENT SYMPTOMS. 

The erythematous eruption on the skin may be pre- 
ceded, accompanied, or followed by more or less well- 
marked inflammation of the pharynx, tonsils, and soft 
palate; mucous patches in the mouth; seborrheica of the 
scalp, alae nasi, and genital organs ; and intertriginous 
in [lamination of the inner surfaces of the thighs, scro- 
tum, or vulva, perineum, and anal fold, called by some 
authors, improperly, " syphilitic eczema; " loss of hair, 
a small pustulo-crustaceous eruption of the scalp, artic- 
ular pains, and, after longer continuance, papules, pus- 
tules, condj'lornata lata, etc. Hyde l mentions wandering 
pains in the extremities, and especially beneath the 
sternum, as frequent and " highly significant " symptoms 
of the erythematous syphilide. 

DIFFERENTIAL DIAGNOSIS. 

The erythematous syphilide is a frequent source of 
error in diagnosis. It may be confounded with measles, 
rotheln, scarlet fever, typhus and typhoid fevers, the 
prodromal erythema of small-pox, various erythematous 
eruptions due to the ingestion of certain drugs, non- 
specific erythemata, tinea A^ersicolor, and ringworm. 

Measles is always preceded b} T catarrhal irritation of 
the eyes, nose, and air-passages. The fever is also more 
marked than in the syphilitic exanthem. The eruption 
in measles is papular, the papules being closely aggre- 
gated, the patches having a crescentic arrangement. 
The face is usually first affected in measles, while in 
syphilis it is nearly always exempt from the eruption. 

1 Diseases of the Skin. Phil a., 1883. 



The Cutaneous Manifestations of Syphilis. 225 

From the face the exanthem spreads over the whole sur- 
face of the body usually within twenty-four or thirty^six 
hours. The development of the syphilitic eruption is 
never so rapid as this. 

From rotheln, the erythematous syphilide may be 
differentiated by the bright color of the former erup- 
tion, its papular character, and its brief duration. The 
eruption of rotheln appears rapidly, and fades away 
again in a day or two. The rash is also more profuse 
than the sj'philitic exanthem. 

Scarlet fever has such a characteristic clinical history 
that it would seem that no difficulty could arise in the 
differential diagnosis between this disease and the er} T - 
thematous syphilide. The points of distinction are the 
high temperature, uniform, confluent, and extensive erup- 
tion and scarlet color of the latter. The comparative 
freedom of the face from the eruption and the anginose 
S3*mptoms may lead to error, if the other marks of 
distinction are not borne carefully in mind. 

The rose colored eruption in typhoid fever may sim- 
ulate the erythematous S3 r philide. The distinct lenticu- 
lar character of the eruption and the sparseness of the 
lesions, together with the other clinical SA'mptoms of 
typhoid, will, however, serve to distinguish the two 
affections. 

The mottling of the skin and the macular eruption 
in t} r phus fever could be readily mistaken for the ery- 
thematous syphilide, if the presence of the fever and 
the profound disturbances of function in typhus could 
be overlooked. The clinical features of this fatal dis- 
ease are so marked, however, that no such mistake in 
diagnosis as here indicated ought ever to occur. 

The prodromal eiythema of small-pox is usually 
limited to the lower portion of the abdomen, the genital 

10* 



226 Diseases of the Skin. 

region, and the upper third of the thighs. It is bright 
red, equally diffused, and not disseminated in spots. 
There is usually high fever also. 

One of the erythemata not infrequently mistaken 
for the erythematous syphilide is the eruption some- 
times following the ingestion of copaiba and cubebs. 
So frequently does this eruption follow the use of these 
drugs that some writers, notably Cazenave, taught that 
gonorrhoea is accompanied by an eruption resembling- 
one of the S} 7 philides. It is now established, however, 
that this " gonorrhoea! erythema ,? occurs only in those 
cases who take copaiba, cubebs, or drugs of similar 
character. 

Accompanying such a common venereal disorder, 
and therefore extremely liable to cause errors in diag- 
nosis, the differentiation of this eruption demands some 
attention. The copaiba rash appears suddenly and 
rapidly becomes confluent and ma3 r cover the entire sur- 
face of the body like a sheet. Usually, however, the 
patches are grouped in localities where the skin is sub- 
jected to pressure, as, for example, about the neck, 
wrist, waist, etc. The face is not exempt. The erup- 
tion is accompanied by violent itching and burning, and 
there is generally some heat and tumefaction of the skin, 
symptoms which are absent in the erythematous syphi- 
lide. The eruption disappears in a few clays if the drug 
is omitted. 

In exceptional cases the administration or external 
application of mercurials may cause an eruption bearing 
some resemblance to the erythematous sypiiflide. Cases 
have been reported b} T Zeissl and Baumler. It seems 
to be extremely rare. Benzoate of sodium, an ti pyrin, 
and some other drugs ma} r cause an erythematous erup- 
tion, but in the former case the rash is especially local- 



The Cutaneous Manifestations of Syphilis. 227 

ized about the face, while the antipyrin eruption is 
usuall} T very itchy. Erythema multiforme, in its varied 
manifestations, is usually easily diagnosticated from the 
erythematous syphilide. The non-specific eruption occurs 
in large patches with crescentic margins, appears, runs 
its course, and disappears in a few days, and is especially 
localized about the backs of the hands, wrists, and 
ankles, — parts especially exempt from the syphilitic 
eruption. 

The eruption that is most frequently mistaken for 
the erythematous syphilide is tinea versicolor, one of the 
parasitic skin diseases. The localization of the erup- 
tion, its appearance, absence of fever and subjective 
symptoms, and its chronicity, all combine to give it a 
close resemblance to the specific eruption under consid- 
eration. The points of distinction are : the absence of 
a history of syphilis, the desquamation, the generally 
darker pigmentation, and the limitation, usually, of the 
eruption to the trunk, in the parasitic affection. A posi- 
tive means of distinction is the recognition of the mj'ce- 
lial elements and spores of the microsporon furfur in 
the scales when examined under a microscope. 

In recurrent erythematous syphilide, limited to the 
prepuce and gians, or the vulva, the eruption may give 
rise to the impression that it is a case of simple balanitis, 
or vulvitis, or, on the other hand, as already mentioned, 
the erosions produced ma}^ be considered as primary 
syphilitic lesions, which impression may be strengthened 
by subsequent infection of healthy persons during the 
sexual embrace. The annular form of the recurrent 
syphilide may be mistaken for erythema annulare or 
tinea circinata. The former is characterized by its 
localization, which is nearty alwa} T s on the backs of the 
hands, while in the 'latter the mycelial elements and 



228 Diseases of the Skin. 

spores of the trichophyton tonsurans can nearly always 
be found on careful microscopical examination. 

MINUTE ANATOMY OF THE ERYTHEMATOUS SYPHILIDE. 

The histology of the erythematous syphilide has 
been studied by Biesiadecki and Kaposi. The former 
found cellular infiltration of the tissues immediately 
around the capillary blood-vessels. The adventitia of 
the larger vessels of the corium contains round and 
spindle-shaped cells within the area of the lesion. The 
calibre of the capillaries leading to the papillae is some- 
what narrowed, owing to the cell-proliferation in the 
adventitia. In the papillae themselves the vessels seem to 
be somewhat dilated. The connective-tissue corpuscles 
also show changes indicating beginning proliferation. 

PROGNOSIS. 

The erythematous sj^philide generally yields readily 
to treatment. According to Zeissl, the eruption, if 
uncomplicated, is a favorable indication, as it shows a 
resistance of the deeper structures to invasion by the 
syphilitic poison. The recurrence of the s3 T philide 
without evidence of involvement of deeper tissues or 
organs is considered an especially favorable sign by this 
eminent syphilographer. 

The Papular Syphilide. 

In a case of syphilis passing through its regular 
evolutionary cycle, the papular syphilide is the second 
in order of the cutaneous manifestations of the disease. 
This lesion appears under several morphological charac- 
ters, which differ so much clinically that they require sepa- 
rate description. In order to distinguish the peculiari- 
ties of each of these varieties of the papular sj T philide, 
it will be well to make the following division : — 



The Cutaneous Manifestations of Syphilis. 229 

(a) The conical papular syphilide. 
(p) The flat papular syphilide. 

(c) The scaty papular syphilide. 

(d) The moist papular syphilide. 

(a) THE CONICAL PAPULAR SYPHILIDE. 

[Synonyms. — Miliary syphilide, lichen syphiliticus, 
the small papular syphilide, papulo-granular syphilide.] 

The eruption of the conical papular syphilide gener- 
ally follows very close! j t upon or may be contempora- 
neous with the erythematous syphilide. Its period of 
eruption is usually completed within a week. Sometimes 
the entire eruption comes out in the course of forty- 
eight hours. It appears in the form of acuminate 
papules, from the size of a minute, punctiform elevation 
to two millimetres in diameter. The color of the pap- 
ules is at first bright red, later becoming brownish or 
livid. The surface is smooth and shiny, except when 
covered with desquamating epithelium. At times the 
apices of some of the papules contain minute droplets 
of serum, constituting small vesicles. Some authors 
have described this stage of efflorescence as a separate 
variety, under the name of the vesicular s} T philide. The 
vesicular stage of the papule is, however, very transient, 
the fluid being either re-absorbed or evaporating, leaving 
the papule capped by a small scale, consisting of the 
upper layer of the epidermis, which has been raised off 
from the rete below by the effused serum. During the 
involution of the eruption, which is usually a very slow 
process when untreated, lasting from two to three 
months, the color undergoes the modifications men- 
tioned, and there is sometimes desquamation of the 
papular summits. In colored patients this is sometimes 
so marked as to give the lesions a distinctly white 



230 Diseases of the Skin. 

appearance. When the papules become absorbed, they 
leave, according to Kaposi, minute depressions of the 
surface, to mark the seat of the lesions. 

The acuminate sypliilide is most freely distributed 
upon the face and back, but no portion of the surface is 
exempt from it. It is less frequent upon the palms or 
soles, where it may be substituted by the flat papular 
eruption. In some situations, particularly the genital 
region and the flexures of joints, it is aggregated in 
solid sheets, from two to five centimetres (one to two 
inches or more) in extent. Fournier describes this as 
a separate variety. The papules are sometimes, though 
not very frequently, arranged in circles or crescentic 
groups. 

Differential Diagnosis of the Conical Papular 
Syphilide. — The disease most likely to be mistaken for 
this form of the papular syphilide is lichen planus. In 
many cases the diagnosis is very difficult unless other 
concurrent specific symptoms are present. I have at 
present under treatment a case of lichen planus in 
which this resemblance is striking. The main points of 
difference are the slower evolution in lichen and the ten- 
dency to become aggregated in patches with a flat sur- 
face. In lichen there is usually itching, while in the 
papular S3 r philide this symptom is rare. Papular eczema 
can generally be excluded by the dull color of the 
eruption and the intense itching. 

Prognosis. — The conical papular syphilide is often 
exceedingly resistant to treatment, and may recur after 
disappearing. The recurrent form — sometimes after 
two or three }^ears after the first outbreak — is usually 
only sparsely distributed in small groups and patches 
in the articular flexures of the elbow and knee 
(Kaposi). 



The Cutaneous Manifestations of Syphilis, 231 

(6) THE FLAT PAPULAR SYPHILIDE. 

[Synonyms. — Lenticular syphilide, large papular 
syphilide, sj^philide merisee.] 

The flat papular syphilide differs from the preceding 
in the size, form, and distribution of the lesions, its fre- 
quency, and its mode of evolution. The lesions vary 
in size from five millimetres to two centimetres (one- 
fourth to three-fourths of an inch) in diameter. They 
are elevated above the skin, and either flat or slightly 
convex on the surface. The papules come out in suc- 
cession, ill a subacute or chronic course, and usually 
persist for months. Their shape is rounded or oval, 
and the color that generally characteristic of the syphi- 
lides. The base of the papules seems to be sunk deeply 
in the skin. They are firm to the touch of the finger, 
and cannot be made to disappear under pressure. The 
surface is either shiny or covered with minute, whitish 
scales. When undergoing involution they become 
smaller and flatter, and, when the infiltration has disap- 
peared, a brownish pigmentation is usually left, which 
slowly fades out, and may give place to a whitish spot, 
indicating deficiency of pigment. There is sometimes, 
also, an absorption of normal tissue, leaving a slight 
atrophic depression to mark the site of the former 
lesion. 

The lenticular syphilide is the most frequent form 
of the papular eruption. It is usually disseminated, 
not aggregated in groups, and may be found on almost 
any part of the surface of the body, although, like the 
other s} r philides, it has certain seats of predilection and 
exclusion. Its favorite points of localization are the 
frontal, fronto-temporal, and occipital margins of the 
hairy scalp, the scapular and sacral region, the genito- 
crural fold, the angles of the mouth and nostrils, the 



232 Diseases of the Skin. 

flexures of the elbows and knees, and the inner surfaces 
of the upper arms and the thighs. The face, except the 
localities mentioned, the extensor surfaces of the limbs, 
and the dorsal surfaces of the hands and feet are 
almost entirely exempt from the eruption of this 
lesion. 

Difficulty in diagnosis can rarely occur between 
the flat papular ayphilkle and other cutaneous affections. 
When the papules are very scaly, they may suggest 
psoriasis; but the different localization, and, indeed, the 
entirely different clinical history of the latter disease 
will furnish a ready means of diagnosis. Subjective 
symptoms are absent in the syphilitic eruption. 

This lesion is, like the miliary syphilide, frequently 
an- early manifestation of syphilis. It is sometimes 
found accom pairing the eiythematous eruption, but it 
is not rare as a late form, being classed by some authors 
among the late secondary or intermediate eruptions. It 
frequently relapses after months or years from the date 
of its first appearance. 

(o) THE SCALY PAPULAR SYPHILIDE. 

[Synonyms. — Syphilitic psoriasis of the palms and 
soles, squamous syphilide, papulo-squamous syphilide, 
lepra syphilitica.] 

This variety of the papular syphilide, although one 
of the most characteristic of the cutaneous manifesta- 
tions of the disease, nevertheless gives rise to more 
mistakes in diagnosis than any other cutaneous lesion. 
Its stud} 7 , therefore, demands especial attention. 

As mentioned above, the erythematous syphilide, 
when it occurs on the palms and soles, frequently be- 
comes scaly. The same modification occurs in the 
papular syphilide when it occupies these localities. 



The Cutaneous Manifestations of Syphilis. 233 

Indeed, the appearance of a papular syphilide of the 
palms is so strikingly different from the same lesion 
occurring upon other parts of the body that in naming 
it the elementary lesion is ignored, and most syphilog- 
raphers speak of it as palmar and plantar psoriasis, 
while others term it the squamous syphilide. Both of 
these names are improperly used, since psoriasis is an 
independent cutaneous disease, as widely different as 
possible in essential nature from S3 T philis, while derma- 
tologists and syphilographers are fully aware that the 
desquamative process in the eruption under considera- 
tion is merely a stage of involution in the history of 
the elementary lesion, i.e., the papule. 

The scaly papular s} T philide develops in the following 
manner: Brownish-red papules, about half a centimetre 
(one-fourth of an inch) in diameter, appear upon the 
skin of the palms and soles. When they are abundant 
they may extend over the palmar and plantar surfaces 
of the lingers and toes. Sometimes, after the affection 
has lasted a long time, the eruption may invade the 
lateral surfaces of the fingers. The dorsum of the hand 
or foot is, however, never attacked. 

At first these papules are not elevated above the 
surface, on account of the thickness of the epidermis, 
but the infiltration can readihv be detected by the touch. 
Gradually the lesions become slightly elevated, and the 
surface becomes hard and callous, like the callosities 
produced by the use of certain tools. Presently the 
tops of the papules become detached spontaneous^, or 
are scratched off by the patient, and leave a red base, 
surrounded by a finely serrated, whitish, scaly margin. 
The young epidermis on the surface of the lesion rap- 
idly becomes dry and is exfoliated, and thus the 
desquamation becomes more or less continuous. 

K 2 



234 Diseases of the Skin. 

The deep lines in the palms and the flexures of the 
fingers are the preferred seats of the papulo-squamous 
eruption. On the plantar surface the concave arch is 
most frequently affected. The constant motion to which 
the integument of the palms is subjected causes deep 
fissures in the infiltrated skin. These sometimes extend 
into the cutis and give rise to severe pain with every 
movement of the hands or fingers. This constitutes 
one of the exceptions to the general rule that the 
syphilides are not accompanied by subjective symptoms. 
The eruption may extend along the fingers and invade 
the matrix of the nails, which become brittle and lose 
their lustre. 

When the lesions have persisted a long time, the 
elementary characters are gradually lost, and a diffused, 
brownish-red infiltration, with a broken, squamous sur- 
face, is seen. In this stage there are often no other 
evidences of syphilis apparent on superficial examina- 
tion, and an exact diagnosis may be difficult. 

Differential Diagnosis of the Scaly Papular Syphi- 
lide. — " Quoties ego video pustnlas istas in capite, aut 
rhagades in manibus, indicium certum profero Gallici : 
caetera sign a fallunt nos,haec certissima sunt " expressed 
the confidence of Gabriel Falloppio in the value of this 
lesion as a diagnostic mark of syphilis. Ricord, more 
positive than his predecessor of the sixteenth century, 
called the papulo-squamous sypliilide of the palm and 
sole " the diagnostic of pox, written on the hand or the 
foot of the patient ; " and Fournier, whom we may 
regard as among the greatest of modern syphilogra- 
phers, states that " palmar or plantar psoriasis is a 
veritable certificate of syphilis, — an authentic certificate, 
— against which there is no possibility of protest." I 
should be glad to accept the assurances of these dis- 



TJie Cutaneous Manifestations of Syphilis. 235 

tinguished musters that a palmar psoriasis is necessarily 
syphilitic, were it not established, by a number of care- 
fully observed and recorded cases, that a non-syphilitic 
psoriasis may occur upon the palms. This fact makes 
it necessary to point out the distinguishing features 
between the scaly sypMlide of the palms and other 
affections that may be mistaken for it. 

The disease most likely to be mistaken for the 
papulo-squamous syphilide is non-syphilitic psoriasis. 
In this disease there is a bright-red, slightly elevated 
base, covered with white, silvery scales. On scratching 
off the scales with the finger-nail, a thin pellicle is 
found, which, if detached, is followed by a droplet of 
blood. The lesion begins as a red papule, which soon 
becomes covered with the white scales, and which 
rapidly extends peripherally, so that, if closely exam- 
ined, the true psoriatic lesion is found to consist of a 
pretty uniform sheet of elevated eruption, while the 
syphilitic manifestation is made up of individual pap- 
ules, more or less closely aggregated, and only incom- 
pletely covered with scales. These are also more firmly 
adherent than in psoriasis, and often consist of little 
plates of cornified epithelium rather than fine, imbri- 
cated scales. Too much stress must not be placed upon 
the appearance of the scales, however, for the occupa- 
tion of the patient, or the attention he pays to the 
cleanliness and culture of the skin generally, may 
materially modify the ordinary appearance of the erup- 
tion. Much more reliance should be placed upon the 
clinical history of the case, for although, as Ricord has 
well said, " the science of the physician is above the 
asseveration of the patient," much help may often be 
obtained from the patient's account of the origin and 
progress of the lesions. In true psoriasis there is 



236 Diseases of the Skin. 

usually a history of repeated outbreaks since early 
youth. Furthermore, the eruption is especially liable 
to be localized upon the extensor surfaces of the ex- 
tremities, the elbows and knees and the skin over the 
sacrum being the favorite seats of the psoriatic lesions. 
In psoriasis, moreover, there is more or less pronounced 
itching, while this S3 T mptom is generally absent in the 
syphilitic eruption. In cases of doubt, the aid of medi- 
cinal treatment may be invoked, in order to clear up 
the diagnosis. The syphilide will resist arsenic and 
yield to mercury, while psoriasis generally disappears 
if arsenic be given, but is not affected by mercury. 

In scaly eczema of the palm there is always the char- 
acteristic infiltration, giving the peculiar u leathery " feel 
to the skin when pinched up ; the itching is usually 
very troublesome, and there is a history of occasional 
vesiculation and "weeping" of the affected surface.' 
The thickened skin is often deeply fissured, and the 
fissures may bleed or exude serum and cause severe 
pain at eveiy movement of the fingers or hand. Upon 
the soles the epidermic accumulation is sometimes 
exceeding^ great, being at times from one-half to one 
centimetre (one- fourth to half an inch) in thickness. 

(d) THE MOIST PAPULAR SYPHILIDE. 

[Synonyms. — Mucous patches of the skin, cond}do- 
mata lata, pustula foeda ani, moist papules, plaques mu- 
queuses, schleimpapeln, feigwarzen.] 

Upon surfaces of the skin more or less constant!} 7 in 
contact with one another, as in the genital and perineal 
regions, the gluteal folds, the axillae, between the toes, 
the folds of pendulous breasts, the umbilicus, or, in fact, 
any portion of the surface kept constantly moist and 
warm, the papular s} T philide undergoes certain trans- 



The Cutaneous Manifestations of Syphilis. 23t 

formations which necessitate description. The papules 
developing in such parts become macerated, the epithe- 
lial covering* becomes softened and destroyed, and the 
whitish moist surface of the rete mucosum, with numer- 
ous little red points indicating the summits of the 
papillae, presents itself to view. 

The warmth and moisture tend to increase the nu- 
trition of the parts, and the papular lesions, which on 
other dry portions of the cutaneous surface rarely ex- 
ceed a diameter of half a centimetre, here undergo an 
excessive development, and the moist papular syphilide 
varies in size from one to two, three, or four centimetres 
in diameter. 

These broad condylomata are distinctly elevated 
above the surface of the surrounding skin with a sharply 
defined margin, have a pinkish, bluish, or brownish sur- 
face, and discharge freely an offensive puriform secre- 
tion. The surface is sometimes much elevated, consti- 
tuting a fungoid growth. Sometimes a large number 
of these mucous patches are closel} r aggregated together 
on surfaces especially favorable to their development. 
This is particularl}' liable to occur about the genitals, 
anus, or perineal region. I have seen a case in which 
the vulva, perineum, and the inner surfaces of both 
thighs nearl} r to the knees were so thickly covered with 
profusely secreting moist papules that the raw surface 
looked like a continuous erosion or ulceration, elevated 
above the surface. At the borders of such a patch, where 
the skin is kept dryer, the papules are less thickly scat- 
tered, and gradually the moist tj T pe is entirely lost, and 
the usual form of the dry papular syphilide is met with. 
Sometimes the moist surface undergoes ulceration, at 
others it becomes diphtheritic. In either event a loss 
of substance and healing by cicatricial tissue is likely to 



238 Diseases of the Skin. 

follow. This is especially seen in those moist papules 
occurring on mucous membranes, as in the mouth, 
where the mucous patch is generally found in the shape 
of an ulcer. 

Moist papules are among the most frequent early 
constitutional manifestations of syphilis. Their secre- 
tion is highly contagious, and from their situation they 
are particularly liable to propagate the disease. 

Lancereaux 1 gives tables compiled from the works 
of Davasse and Deville, and Bassereau, showing the 
seats of predilection of this lesion in the two sexes. 

In 186 women, the moist papules were seated : — 

Upon the vulva, 174 times. 

Upon the amis, 59 times. 

Upon the perineum, 40 times. 

Upon the buttocks and inner surface of the thighs, 
38 times. 

Upon the tonsils, 19 times. 

Upon the nose, 8 times. 

Upon the tongue, 6 times. 

Upon the toes, 5 times. 

Upon the face, 5 times. 

Upon the navel, 3 times. 

Around the nails, twice. 

Upon the ears and velum palati, twice. 

Upon the inguinal fold, twice. 

Upon the neck, nipple, and cervix uteri, once, 

In 130 men, the seat of the lesion w r as : — 

At the anus, 110 times. 

Upon the tonsils, 100 times. 

Upon the scrotum, 60 times. 

Upon the lips, 55 times. 

Upon the glans and internal surface of the prepuce, 

28 times. 

1 Traite de la Syphilis, p. 168. 



The Cutaneous Manifestations of Syphilis. 239 

Upon the pillars of the palate, the tongue, and the 
internal surface of the cheeks, 73 times. 

Between the toes, 11 times. 

In the geni to-crural fold, 5 times. 

At the orifice of the nares, twice. 

Upon the posterior wall of the pharynx, twice. 

At the insertion of the toe-nails, twice. 

At the meatus urinarius, in the axilla, upon the gums, 
and the internal face of the thighs, once. 

Despres l has reported live cases in which the moist 
papular syphilide was found in the external auditory 
meatus. The lesions have also been observed upon the 
external ear, the vocal chords, the lachrymal caruncle, 
and the conjunctiva. 

Differential Diagnosis of the Moist Papule. — The only 
affection with which the moist papule or mucous patch 
is liable to be confounded is the pointed venereal wart, 
or gonorrhoeal wart. The lesions are essentially different 
not only in their histology, but in macroscopic appear- 
ance, and attention is merely called to their difference 
here because the pointed warts are sometimes assumed to 
be syphilitic manifestations by careless observers. In 
rare cases, an excessively irritated ringworm of the genito- 
crural region may simulate the moist papular syphilide; 
but the free secretion, the offensive odor, the absence of 
itching, and the distinct elevation of the affected sur- 
face above the level of the skin in the latter will usually 
suffice to distinguish it from the non-specific disease. 

MINUTE ANATOMY OF THE PAPULAR SYPHILIDS. 

The histology of the syphilitic papule has been care- 
fully studied by Cornil and Kaposi. The epidermal 
layer and the rete are preserved in the dry papule. The 

1 Cornil on Syphilis. Philadelphia, 1882, p. 131. 



240 Diseases of the Skin. 

rete is, however, thinned at the apex of the papular lesion. 
At times the line of demarcation between the corium 
and the mucous layer is indistinct. The rete cells are 
dentated and have vacuoles. This is well shown in Figs. 
33, 35, and 36 of Cornil's work on " Syphilis." * Similar 
changes occur in the moist papule or mucous patch. 

The corium and papillae are infiltrated with small 
round cells which resemble white blood-corpuscles, but 
are usually much smaller. The papillae are hyper- 
trophied and project into the mucous layer, while the 
interpapillary prolongations of the rete also project 
deeper than normally into the connective-tissue layer. 
The color of the syphilitic papule is partly due to con- 
gestion and partly to actual extravasation from the 
enooro;ed blood-vessels. Giant cells are also found in 
the cutis. The walls of the blood-vessels are studded 
with highly refractive nuclei, but the calibre of the 
vessels seems to be normal. 

In the moist pa pules the same general histological 
features are maintained, but the papillae are very much 
increased in size and knobbed or branched at their 
extremities. In the centre of a suppurating mucous 
patch, however, the epithelial layer may have entirely 
disappeared and the ulcerating surface of the papillae, 
or even of the cutis itself, may present itself to view. 

PROGNOSIS OF THE PAPULAR SYPHILIDE. 

The papular syphilide usually runs a chronic course, 
but is easily influenced by appropriate treatment. 
Local as well as general measures must be employed. 
Moist papules are particularly liable to recur. 

The Pustular Syphilide. 
The pustular syphilide is generally the result of a 
breaking down of a papular eruption, and, were it not 



The C ataneous Manifestations of Syphilis. 241 

for its clinical importance, .should be described as a 
sequel of the papular lesions. It is met with in several 
forms, but a sufficiently accurate classification is into 
two varieties, — the small or miliar} 7 and the large or 
lenticular pustular sj-philide. 

(a) THE SMALL PUSTULAR SYPHILIDE. 

[Synonyms. — Herpetiform syphilide, syphilitic acne, 
miliary syphilide, impetiginous syphilide, SA'philitic 
impetigo.] 

The small pustular syphilide generally results from a 
transformation of small papules. The apices of the 
papules become converted into a small collection of 
pus, which dries into a thin, fragile crust. The eruption 
is localized upon the same portions of the surface 
affected by the small papular syphilide, namely, the 
face, shoulders, and trunk. It is sometimes dissemi- 
nated OA r er the whole surface, and at others especially 
localized in groups about the joints, the hairy margin 
of the scalp, and the genital region. The pustules are 
usually acuminate, but rarely prominent. They are 
sometimes arranged in circular or crescentic figures. 
The hair and sebaceous follicles are favorite seats of the 
eruption. When involution of the lesion takes place, 
the contents of the pustule dry up, the infiltrated base 
diminishes in size, and absorption of the papular lesion 
is followed by a small spot of pigmentation, which 
gradually disappears, leaving the skin normal in color, 
or marked with white spots, showing atrophy of pig- 
ment. Sometimes, however, a small ulcer remains, which 
may take on destructive action and spread. Moderate 
febrile movement usually accompanies the develop- 
ment of pus in the papular lesions. The course of the 
eruption is very slow when untreated, the lesions suc- 

11 L 



242 Diseases of the Skin. 

ceeding each other in crops for three, four, or even six 
months. 

The pustular syphilide is especially frequent in the 
colored race. Among whites, it, as a rule, affects only 
subjects of depressed vitality ; for example, individuals 
whose health is broken down from overwork, under- 
feeding, exposure, or intemperance. It may occur, how- 
ever, in persons of apparently vigorous health, hi 
these cases, some authors look upon it as an evidence 
of affection by a malignant form of syphilis. I cannot 
agree to this view. In m} r opinion, malignity in syphi- 
lis, as in other infections diseases, is a clinical peculi- 
arity depending upon the individual, and not upon the 
infectious material. 

Differential Diagnosis of the Small Pustular Syphi- 
lide. — The striking similarity to acne, which has given 
to the small pustular syphilide one of its synonyms, 
points to a source of difficulty in diagnosis. The dis- 
tribution of the eruption upon the face, breast, and 
back, as well as the appearance of the lesions in acne, 
closely resemble the syphilitic manifestation. A careful 
examination will, however, detect objective differences 
in the lesions themselves, without the aid which the 
history of the case will give. In adbe the papulo- 
pustules are painful, with a larger inflammatory base; 
the lesions are in varying stages of development ; the 
pus is usually more deeply situated, reaching the surface 
from below; and when the pus is evacuated the involu- 
tion of the infiltration is comparatively rapid. The 
crustiform scab of the S3 T philitic lesion is rarelj^ seen in 
acne. The absence of pain or other subjective symp- 
toms in the pustular syphilide is also an aid in making 
the differentiation. Rarely, cases of pustular eczema, 
especially when affecting the lower extremities, may be 



The Cutaneous Manifestations of Syphilis. 243 

mistaken for the small pustular syphilide. The other 
clinical features of eczema — itching, diffused infiltration, 
and discharge — will enable the distinction to be made 
with little difficulty. 

(b) THE LARGE PUSTULAR SYPHILIDE. 

[Synonyms. — Lenticular pustular syphilide, syphilitic 
ecthyma, varioliform syphilide, syphilitic acne, rupia.] 

The large pustular syphilide presents itself in a 
greater number of varieties than the form just described. 
Its lesions var} r in size from a split-pea to a thumb-nail, 
or larger. The pustules may be elevated above the 
surface, or flat. They are always seated upon a dis- 
tinctly infiltrated base, and in the course of their invo- 
lution become covered with crusts, which ma} 7 attain a 
large size. The lesions are usually disseminated over 
the surface, generally sparing the palms and soles. After 
the crusts fall off, the infiltrated base may undergo a 
slow involution and absorption, or continue as an ulcer- 
ative lesion, to be more described fully later. 

Rupia is a variet^y of the large pustular s^'philide. 
The lesion consists of a pustular ring, whose centre is 
occupied b} r a large, irregularly pyramidal crust. The 
pustular ring is surrounded by a violaceous or bluish 
areola. The pustule and crust increase in size Try 
peripheral extension. The base of the lesion consists 
of a shallow ulceration with a blood}^, ichorous discharge 
on its surface. 

Differential Diagnosis of the Large Pustular Syphi- 
lide. — The large pustular syphilide must be differentiated 
from small-pox, varicella, acne, pemphigus, impetigo 
contagiosa, and various non-specific pustular affections 
described by authors under the names of impetigo, 
ecthyma, etc. 



244 Diseases of the Skin. 

In negroes, the pustular syphilide is at times 
strongly suggestive of small-pox. If a clear clinical 
history can be obtained, the differentiation is usually 
not difficult, but at times much doubt must occur. Thus, 
a colored man lately presented himself in m} T clinic in 
whom a disseminated pustular eruption, covering nearly 
the entire body, had followed a possible exposure to 
small-pox. The case came under observation just about 
the time when a small-pox scare was creating a little 
excitement. The lesions were strikingly like small-pox, 
with the exception that there was no umbilication of 
the pustules. This feature is, however, not an essential 
of the variolous exanthem, except at a certain stage. 
The appearance of lesions in varying stages of develop- 
ment, the length of time the eruption had been out, and 
the absence of fever or systemic depression led to an 
examination of the penis, which disclosed a sclerotic 
infiltration in the fraenum preputii, and enlargement of 
the lymphatic glands of the groin. A diagnosis of pus- 
tular syphilide was made, which was confirmed by the 
subsequent history of the case. 

In cases where the eruption is sparseh' distributed 
the lesions sometimes assume the characters of varicella. 
The diagnosis in such cases can never be long in doubt, 
for the varicellar exanthem rapidly dries up, and besides 
is very rare in adults, who are most likely to be the sub- 
jects of acquired syphilis. Acne is sometimes mistaken 
for the large pustular sj'philide, but the diagnostic 
marks of this disease pointed out above should suffice 
to distinguish the two affections. 

A variet}' of the large pustular syphilide, termed by 
some authors the bullous syphilide, may sometimes be 
mistaken for pemphigus, and conversely. The bullous 
syphilide is very rare as a symptom of acquired s} T philis, 



The Cutaneous Manifestations of Syphilis. 245 

being nearly confined to children who are subjects of in- 
herited syphilis. The " syphilitic pemphigus," so called, 
is a grave symptom, and differs from true pemphigus in 
having blebs with purulent contents and an inflam- 
matory border, and leaving an eroded or ulcerated 
base when the contents of the bullae are evacuated or 
dried up. Impetigo contagiosa is so peculiar in its lo- 
calization and appearance, being limited to the face and 
hands, evidently contagious and rapidly drying up, the 
lesions passing through their periods of development and 
involution usually within two weeks, that only a care- 
less observer would fail to distinguish this disease from 
a syphilitic eruption. 

Certain non-specific pustular eruptions, described by 
some authors under the names of impetigo and ecthyma, 
are sometimes mistaken for the pustular syphilids 
These lesions usually occur in debilitated subjects, and 
can generally be traced to some local irritation. Thus, 
they are especially liable to occur in persons infested 
with pediculi, or scabies. Sometimes they are seen in 
individuals exposed to stress of weather, overwork, and 
improper or insufficient food. I have seen these atonic 
eruptions frequently in sailors and in the children of the 
poorest classes. The resemblance to the large pustular 
syphilide is so close in many cases that an absolute di- 
agnosis is impossible unless the history of the patient 
is taken into consideration. Cleanliness, good food, and 
rest will, however, soon cause the non-specific eruption 
to disappear, while the\ r have slight influence upon the 
syphilitic manifestation. 

PROGNOSIS OF THE PUSTULAR SYPHILIDE. 

The prognosis of the suppurative lesions of syphilis 
is less favorable than that of the other manifestations 



246 Diseases of the Skin. 

of the disease heretofore considered. The concurrent 
symptoms are sometimes grave. Among the most con- 
stant is fever, which may be continuous and is probabl} T , 
in part at least, septic in character. Suppurative iritis, 
onychia, induration of the testicle, joint-pains, pharyn- 
geal and tonsillar ulcerations and alopecia are frequent 
concomitants. The large pustular syphilide, especially 
if followed by chronic ulcerative lesions, is of serious 
prognostic significance, inasmuch as it indicates a de- 
pravement of the constitution and diminished capacity 
of resistance to injurious influences. 

The pustular syphilide is sometimes contemporaneous 
with the earlier manifestations of the disease, such as 
eiythematous and papular eruptions. Except in colored 
patients, or in whites of broken-down constitutions, the 
pustular syphilide rarely occurs within six months after 
infection. If treatment of the disease has been earl} 7 
instituted, this eruption may never appear, or may be 
delayed for upward of a year. 

Tertiary Syphilitic Eruptions. 

In its eaii}^ stages syphilis presents many of the 
clinical features which characterize the history of the 
eruptive fevers. There is a period of incubation, of 
febrile disturbance, and of eruption on the cutaneous 
and mucous surfaces, as described on preceding pages. 
Then the disease seems to disappear entirely, and the 
patient's usual condition of health is apparently re- 
established. In perhaps one-half the cases the end of 
the eruptive stage marks the termination of the disease; 
but, in the remaining half, after a varying interval, 
known as the period of latency, a series of lesions appear, 
which present marked differences from those that have 
gone before. While in the secondary or eruptive period 



The Cutaneous Manifestations of Syphilis, 247 

the manifestations of the disease are symmetrical, and 
the disease itself contagious and inoculable, both by 
means of the blood and particular secretions, normal or 
pathological, and transmissible to the offspring of dis- 
eased parents, these characteristics are not present when 
the disease has passed the secondary period. If the late 
or tertiary symptoms manifest themselves, they are 
more distinctly localized, are unsymmetrical, and, as a 
further point of distinction, do not yield readily to the 
same treatment. Furthermore, in this stage the blood 
and the products of the lesions are no longer regarded 
by man}- as inoculable, while some hold that hereditary 
transmission of the disease is no longer possible. 

It may be stated, however, that many syphilologists 
of deserved high standing do not regard the last two 
propositions as incontestably established. 

These peculiarities in the clinical history of sy^philis 
have led Hutchinson to express the opinion that the so- 
called tertiary lesions of syphilis are merely sequelae, 
and that at the time of their appearance the syphilis no 
longer exists in the individual. Hutchinson's view has 
been adopted by Baumler, who has written what seems 
to me to be one of the best treatises on s} r philis acces- 
sible to English readers. 1 Previous to Hutchinson, 
Virchow had already expressed the opinion that the 
tertiary symptoms of syphilis were due to renewed 
infection of the blood from local residual depots of 
syphilitic virus in the body. The English surgeon, 
however, is disposed to deny any blood-infection after 
the termination of the secondary, or eruptive period. 
The question cannot yet be regarded as settled. While 
Hutchinson's views have much plausibility, the evidence 
in their favor is Iry no means so direct and definite as he 

1 Zierassen's Cyclopedia, vol. iii. 



248 Diseases of the Skin. 

chums, and, from a purely clinical stand-point, it will be 
advisable to consider the tertiary period as still a stage 
in the development of syphilis. An additional reason 
for considering this period as a true stage of syphilis, 
and not as a mere sequela, is, that it is really the most 
grave period of the disease. The early stages of syphilis 
are not periods of danger to life ; but in the gummatous 
stage, when important internal organs become affected, 
the disease frequently proves fatal. Hence, the period 
of gummatous lesions of the skin is one of great prog- 
nostic importance; for, when gummata occur in the 
skin, they are probably also invading internal organs. 

THE TUBERCULAR SYPHILIDE. 

[Synonym. — Syphilitic lupus.] 

The tubercular syphilide marks, in a general wa} 7 , the 
transition from the so-called secondary to the tertiary or 
gummatous stage of syphilis. In fact, the s} T philitic 
tubercle is, anatomically, practically a gummy tumor of 
the skin. However, the degree to which the gummatous 
or specific granulomatous material is infiltrated seems 
less in the tubercular syphilide than in the true gumma. 

This lesion is one of the later manifestations of 
syphilis. It rarely occurs before the third year after 
infection, and may be delayed for five or ten years or, 
perhaps, even longer. 

The syphilitic tubercle appears in the form of pinkish- 
to brownish- red or violaceous lesions, varying in size 
from a split-pea to a bean or larger. The nodules are 
circumscribed, easily defined against the surrounding 
skin, and extend through the entire thickness of the 
integument. The} r may be flat or project above the sur- 
face. They are usually firm to the touch, and the colon 
only partially disappears under pressure with the finger. 



The Cutaneous Manifestations of Syphilis. 249 

The tubercular nodules may be single or multiple. In 
the latter ease thej r are usually aggregated in groups 
forming small nodular patches.- There may be healthy 
skin between the individual tubercles, or these may be 
so thickly set together as to give the appearance of a 
uniformly-infiltrated patch. Should the patch increase 
in size, it seldom does so equally in all directions, but 
progresses in one direction, while retrogressive changes 
follow. 

The evolution and course of this syphilide are es- 
sentially chronic. It develops slowly and may last 
for months without change, simulating various other 
new formations of the skin, such as lupus, leprosy, or 
cancer. 

The tubercular syphilide may occur on any region 
of the bod}\ It is, however, most frequently found 
upon the forehead, nose, and lips, or at the angles of the 
mouth. On the trunk the seat of predilection seems to 
be the scapular region. The extensor surface of the 
forearm near the elbow is also frequently the seat of the 
eruption. 

The conformation of the tubercular patches is some- 
times very remarkable. I have seen one case in which 
the groups of tubercles were situated about the area of 
distribution of a branch of one of the thoracic nerves, 
resembling, on superficial examination, the pigmentations 
following an eruption of herpes zoster. 

Concurrent Symptoms. — Among the manifestations 
of syphilis which accompany the tubercular eruption are 
paronychia, lesions of the nervous centres, mucous 
patches, endarteritis, cachexia, purulent iritis, and 
alopecia. It is rare to find any remains of the in- 
itial induration contemporaneous with the tubercular 

syphilide. 

11* 



250 Diseases of the Skin. 

Differential Diagnosis of the Tubercular Syphilide. — 
The disease with which the tubercular syphilide is most 
frequently con founded is lupus. In fact, the resemblance 
is often so great that some authors have cut the Gordian 
knot by describing a syphilitic lupus. This is an equivo- 
cal and indefinite expression, and should be discount- 
enanced. It is much better to avoid making a diagnosis 
altogether than to use a term which is vague and mean- 
ingless. 

By careful attention to the clinical historj" and ap- 
pearance the diagnosis between these two affections can 
usually be made. Lupus nearly always begins before the 
twentieth year, and in the majority of cases, probably, 
before puberty. A tertiary syphilide is unlikely to 
occur before adult life is reached. Lupus is much 
slower in its progress than syphilis. The advance of 
the lupous infiltration is measured by years ; that of the 
tubercular syphilide by weeks or months. Should ulcer- 
ation occur, the destruction by the syphilitic process is 
much more rapid than by the lupus ; the ulcer in the 
latter disease is more likely to be shallow, with sloping 
borders and non-infiltrated base. The syphilitic ulcer is 
deep, with a punched-out appearance, and covered with 
a profuse, offensive secretion, or with dirty-greenish, 
massive crusts. In lupus the ulcer is generally painless, 
while the contrary is the case with the ulcer of syphilis. 
Finally, if doubt still exists, the aid of antisyphilitic 
treatment may be invoked to clear up the diagnosis. 

Sycosis may sometimes closely resemble a tubercular 
or gummatous syphilide. In sycosis the inflammatoiy 
S3 T mptoms are usually predominant, while they are want- 
ing in the syphilitic growth. In the latter the demarca- 
tion between normal and diseased skin is usually clearly 
defined, while in sycosis or other inflammatory tubercu- 



The Cutaneous Manifestations of Syphilis. 251 

lar affections the redness of the skin shades off gradually 
into the normal color. 

The tubercular syphilide may be mistaken for tuber- 
cular leprosy in one of the stages of the latter disease. 
In leprosy, however, the tubercles are likely to be situ- 
ated about the brows rather than at the margin of the 
hairy scalp; the lobes of the ears and tip of the nose 
are also often invaded, and superficial ulceration of 
these spots of infiltration is not uncommon. There is 
usually anaesthesia of the leprous tubercles, and a care- 
ful microscopic examination by an expert bacteriologist 
will discover the bacillus leprae. The thickening of the 
ulnar nerve and the anaesthesia of the hands will also be 
aids in the diagnosis. 

Some cases of dry, scaling, tubercular syphilide may 
simulate psoriasis, but the limited extent of the lesions, 
the character of the scales, and the difference in appear- 
ance of the infiltrated base will suffice to distinguish the 
two affections. 

Prognosis of the Tubercular Syphilide. — The prog- 
nosis, so far as the lesion itself is concerned, is favor- 
able. With proper treatment it can usually be cured 
with comparative rapidity. When it advances to ulcer- 
ation, instead of undergoing resolutive absorption, it 
may produce disfiguring scars or destroy important 
structures. It is as an index of the stage of the luetic 
disease itself, however, that the tubercular syphilide has 
a prognostic importance. It is in the stage of gumma- 
tous formations when important internal organs, brain, 
liver, kidneys, lungs, and heart become affected. Hence, 
the appearance of tubercular or gummatous lesions of 
the skin is a warning that similar processes are probably 
going on in the internal organs, and demand prompt and 
appropriate measures for their arrest. 



252 Diseases of the Skin. 

THE NODULAR SYPHILIDE. 

[Synonyms.— Gummous sypkilide, gummy tumor, 
syphilitic gumma, syphiloma.] 

The true gummatous syphilide is a late or tertiary 
lesion. It may attack any tissue or organ in the body. 
It was noticed and described by some of the earliest 
writers upon the venereal disease. Juan Almenar 
(1502), Ulrich von Hutten and Giovanni de Vigo 
(1519), Jerome Fracastori (1530), Nicolas Massa 
(1532), Leonardo Botallo (1563), and Gabrielle Fallop- 
pio (1565), all referred to the occurrence of gummata 
in the course of syphilis. Falioppio apparently first 
gave currency to the belief, which has found defenders 
in more recent times, that the administration of mer- 
cury was responsible for the appearance of gummy 
tumors. Ulrich von Hutten had, however, previously 
pointed out that gummata occurred in those who did 
not take mercury as well as in those who used this 
remedy. 

The gummy tumor is a specific manifestation of 
syphilis. It is found in no other disease, and is, when 
present, characteristic of syphilitic infection. It occurs 
in the form of globular nodules, beginning in the deeper 
layers of the skin, or the subcutaneous connective tissue. 
When the tissue in which the nodules develop is loose, 
they are movable and non-adherent. Later, as the}^ in- 
volve the upper layers of the skin and cause irritative 
inflammation, the} r become adherent. Usually gummata 
are not painful, unless seated over nerves, or the inflam- 
matoiT process accompanying them invades the skin, 
periosteum, or serous membranes, when they cause ex- 
quisite suffering. At first the normal color of the 
integument is preserved, but, later, it becomes pinkish, 
red, brown, or bluish red. In size the nodular syphilide 



The Cutaneous Manifestations of Syphilis, 253 

varies from a pea to an almond. In some cases the 
tumors may reach the size of a hen's egg, but this is 
rare. 

The nodules may undergo resolution or suppuration. 
In the former ease the growths become softer, flattened, 
and gradually disappear, leaving a grayish pigmentation, 
which slowly gives place to a slight atrophic spot, show- 
ing deficiency of pigment. 

In by far the larger number of cases the gummy 
tumor breaks down and ulcerates. The centre becomes 
softened, and the skin is finally perforated in one or 
more places, discharging a small quantity of sanious 
purulent matter. The mass of infiltration constituting 
the tumor rapidly undergoes suppuration, and a ragged, 
undermined ulcer is produced, which sometimes extends 
through all intervening tissues to the bone. This is 
frequentlj' observed in gummy tumors of the forehead 
and scalp. After the infiltrated material has all been 
thrown off by suppuration, granulation begins, and the 
ulcer may heal, leaving a pigmented scar to mark its 
location. 

As already mentioned, the tertiary manifestations of 
syphilis are seldom symmetrical. They are also more 
limited in distribution and extent than the secondary 
eruptions. The nodular S} T phi Hole may be limited to a 
single lesion, but, commonly, the tumors are more 
numerous. 

Minute Anatomy of the Nodular Syphilide. — Some 
pathologists have claimed that the histological elements 
of a syphilitic gumma possess specific characters by 
which the} r can be at all times recognized by competent 
observers. Virchow, however, pointed out that this 
view is not tenable, as the syphilitic infiltration does 
not differ from that peculiar to the class termed by him 



254 Diseases of the Skin. 

granulomata, to which lupus, leprosy, and tubercle also 
belong. Since the discovery of the bacilli of leprosy 
and tuberculosis, the new formations in these diseases 
can be easity differentiated, and the recognition of the 
tubercle bacillus in lupus gives an additional diagnostic 
aid between this affection and a syphilitic new growth. 
It is possible that a confirmation of the asserted dis- 
covery of a specific microbe of syphilis, by Lustgarten, 
and by Disse and Taguchi, may give the pathologist a 
means of always making a positive diagnosis of a syph- 
ilitic infiltration by means of the microscope. At pres- 
ent the histological diagnosis of syphilis is beset with 
as man} 7 difficulties as are those of cancer and sarcoma. 
The relations of the infiltrated elements to each other 
and to the tissue in which the}^ are imbedded, must be 
considered as well as the characters of the individual 
elements themselves. 

The gummy nodule consists, according to Kaposi, 
of a " uniform, dense, small-celled infiltration of the 
affected tissue. It is not accompanied by the phenomena 
of inflammatory infiltration, such as serous transuda- 
tion, vascular dilatation, and looseness of texture of the 
connective tissue, but, on the contrary, the infiltrated 
area is drier and denser than normal." Around the 
circumference of the infiltration there is irritative in- 
flammation with consequent new formation. This is not 
specific in character, however, and may undergo or- 
ganization into cicatricial tissue, which never occurs 
with the syphilitic infiltration itself. The latter is either 
absorbed or is thrown off by suppuration or sloughing. 
It never becomes organized into stable tissue. 

Differential Diagnosis of the Nodular Syphilide. — 
The diagnosis often presents considerable difficulty. 
When the gummy tumor is softened and on the point 



The Cutaneous Manifestations of Syphilis. 255 

of breaking through the skin, the resemblance to a boil 
or an abscess is often very great. Even when perfora- 
tion has occurred, the gumma may readily be confounded 
with a boil or carbuncle. The throbbing pain and fever 
of the furuncle may aid in the diagnosis, but a gummy 
tumor, in certain situations, may be extreme^ painful. 
Boils and carbuncles usually develop rapidly, while the 
evolution of a syphilitic nodule is slow, requiring weeks 
before the covering of integument is sufficiently softened 
to permit perforation. Should a gumma be incised in 
mistake for a boil, the character of the contents will 
readily distinguish it from the latter. 

Enlarged Emphatic glands and scrofulous infiltration 
of the skin not rarely present a remarkable resemblance 
to the gummatous syphilide. The glands can, however, 
usually be isolated in their proper anntomical location, 
while the diffuse, strumous infiltration which is sometimes 
seen, especiall} r about the neck, is usualty extensively 
undermined, and the soft, diseased skin perforated at a 
number of points, from which a thin pus is discharged. 
The scars of scrofuloderma are also intersected by 
ridges or papillary elevations. The scar following a 
syphilide is usually depressed and atrophic, although 
in rare instances it may present the characters of 
keloid. 

Epithelial molluscum may simulate the nodular 
syphilide. I have recent^ seen a case of this affection 
in a colored woman, in which even the contents of the 
tumor consisted of a gummy fluid. The principal points 
of differentiation are the number of lesions (these are 
much more numerous in molluscum) and the non-indu- 
rated base and border of the nodules in the hitter affec- 
tion, and the slight umbilication marking the duct of the 
gland whose cystic dilatation causes the disease under 



256 Diseases of the Skin, 

consideration. In most cases, also, the molluscum 
nodules have a constricted neck, i.e., are pediculated. 

Lenticular cancer of the skin is another affection 
sometimes mistaken for the nodular syphilide. It occurs 
in hard, flat, or slightly convex, definite!} 7 ' circumscribed 
nodules, which are usually secondary to a carcinomatous 
growth in the vicinity. The surface of the cancerous 
nodules is smooth, shiny, of a pinkish color, and well 
supplied with blood-vessels. They do not soften down 
in the centre, like gummy tumors, but. ulcerate 
superficially. 

Fatty tumors may be confounded with syphilitic 
gummatous nodules. Their slow development, soft and 
semi-elastic consistence, and absence of all induration 
will suffice to make the distinction. 

The tumors of erythema nodosum, especially when a 
clear history of the case cannot be obtained, may simu- 
late very closely the gummatous syphilide. If the 
patient be kept under observation a few days, a diagno- 
sis can usually be made with little difficulty. The lesions 
of erythema nodosum pass through their successive 
stages of development much more rapidly than those of 
the nodular syphilide. The accompanying symptoms, 
such as pain, localization of the lesion, fever, and color 
of the nodules may be the same in both affections. 
Hence an absolute diagnosis is sometimes not possible 
at sight. 

Multiple sarcoma of the skin may very readily be 
mistaken for the nodular syphilide. The tumors develop 
slowly, are non-inflammatory, are often of a brownish 
color, and sometimes soften in the centre in a manner 
to closely resemble the syphilitic nodules. It is ex- 
tremely important to make the distinction, since the 
prognosis differs so widely in the two diseases. In some 



The Cutaneous Manifestations of Syphilis. 257 

cases, nothing short of the aid of a trial of specific 
medication will enable one to make a positive diagnosis. 
When the disease is advanced and ulceration of the sar- 
comatous lesions has begun, the differentiation is less 
difficult. Happily, multiple sarcoma is very rare, and 
this diagnostic problem will seldom present itself for 
solution. 

Prognosis of the Nodular Syphilide. — The stage of 
syphilis characterized by the manifestations described 
above is the most serious in the history of the disease. 
During the secondary stage, or period of symmetrical 
eruption, the lesions are more or less superficial, but in 
the tertiary stage the deeper structures and organs are 
liable to invasion. Hence the appearance of superficial 
gummata, although the lesions in themselves are, per- 
haps, of little import, calls attention to the fact that the 
syphilitic virus is not entirely eliminated, and may at 
any time cause serious mischief. For this reason the 
gummatous syphilide is always of grave prognostic 
significance. 

THE ULCERATING SYPHILIDE. 

As stated on page 211, the ulcerating syphilide is 
consecutive to a syphilitic infiltration which primarily 
assumed one of the manifestations already discussed. It 
may follow the moist papular, the pustular, the tuber- 
cular, or the nodular syphilide. Its clinical importance 
entitles it to separate consideration. It must be remem- 
bered, however, that the syphilitic ulcer is never a 
primary affection, but always consecutive to a previous 
infiltration. 

The syphilitic ulcer possesses certain features which 
distinguish it from other similar lesions. These are a 
rounded shape, steep or undermined, ragged edges, 
infiltrated base and border, and pain and tenderness of 



258 Diseases of the Skin. 

the ulcer. The ulcerated surface is generally covered 
with a grayish-yellow pus, and sometimes a thick, 
-irregular crust masks the destructive lesion beneath. 

The ulceration does not extend beyond the syphilitic 
infiltration. The destructive process ends abruptly 
where healthy tissue begins. This accounts for the steep 
edges of the ulcer. The syphilitic ulcer does not en- 
large unless there is a continuation of the syphilitic 
infiltration at its periphery. When healthy tissue is 
reached, the process of repair begins. This can, how- 
ever, never take place until all the syphilitic new forma- 
tion is absorbed or cast off, either by the ulcerative 
process or b} r therapeutic means. 

The rounded shape of the ulcer is not always main- 
tained as it progresses. It may assume an oval, kidney- 
shaped, or irregular form. Not infrequently cicatriza- 
tion takes place at one segment of the ulcer, while 
destruction advances at another. In other cases, the 
ulcer cicatrizes in the centre and the ulceration extends 
peripherally. When several contiguous ulcers run 
together, or when an ulcer extends over a large surface, 
following the proceeding just described, the lesion is 
called a serpiginous ulcer or serpiginous syphilide. 

Upon the hairy scalp the ulcerating sj-phijide at first 
presents the characteristic steep and ragged edges, but, 
as neighboring ulcers run together and the bottom be- 
comes somewhat covered with granulations, the ulcera- 
tion becomes more shallow, with prominent, undermined 
edges and easily-bleeding base. The secretion is thin, 
sero-purulent-, and offensive. Mixed with the secretion 
from the sebaceous glands it dries into thick, dirty, 
greenish-yellow crusts and scabs which have a rancid 
odor. The pus may penetrate under the scalp and col- 
lect in depending positions, as the back of the neck or the 



The Cutaneous Manifestations of Syphilis. 259 

eyelids, and be accompanied by erysipelas and glandular 
enlargements. The granulations may become hypertro- 
phic, projecting from one-fourth to half an inch above 
the surface. These bleed easily and secrete a serous 
fluid which dries into crusts. These hypertrophic 
granulations sometimes become veritable papillomata. 

The cranial bones are sometimes, though not very 
frequently, laid bare by the ulcerative process. When 
this takes place, necrosis of a circumscribed portion of 
the outer table of the skull is likely to occur. In rare 
cases', even the dura mater is laid bare by necrosis of the 
cranium in its entire thickness. Strange to say, the 
meningeal membrane is very seldom destroyed by the 
ulcerative process. 

The diagnosis of the ulcerative syphilide of the scalp 
is sometimes rendered difficult by the absence of a con- 
nected history, and occasionally by the results of local 
therapeutic interference which may mask the character- 
istics of the affection. I have seen one case of exten- 
sive epithelioma of the scalp in which the diagnosis was 
exceedingly difficult. In fact, the suspicion is still 
strong in my mind that the ulceration in this case was 
syphilitic in the first place, and only became malignant 
in consequence of the long-continued irritation. The 
peculiar and characteristic infiltration of the border is 
the only mark of differentiation between the cancerous 
and syphilitic ulceration. 

Lupus is generally easily differentiated b}- its history, 
the fact that the ulcers are usually shallow and painless, 
not secreting an offensive pus, and extending by nodules 
at the periphery. The secretion and crusts of a lupous 
ulcer of the scalp are usually less profuse and abundant 
than in the ulcerating syphilide. 

That curious disease of the hair-follicles of the oc- 



260 Diseases of the Skin. 

cipital region, described by Kaposi as dermatitis papil- 
laris capillitii, and by English authors as acne keloid, 
bears many resemblances to agummato-uleerating syphi- 
lide. The only point of differentiation to which I can 
call attention is the localization of the eruption and the 
characteristic " bunching "of the hairs in the follicles. 

The syphilitic ulcer of the face sometimes presents 
a very close resemblance to epithelioma. The absence 
of the hard infiltration characteristic of cancer and the 
rapid progress of the syphilitic ulceration will generally 
allow a definite diagnosis. Probably the greatest' diffi- 
culty will be prevented, however, b} r the differentiation 
between the ulcerating syphilide and lupus. When it 
occurs upon the nose the resemblance between the two 
processes is sometimes so close that the best clinicians 
will be unable to make a positive diagnosis. In these 
cases the history of the case will often be a very useful 
aid. Lupus is slow in progress, and in by far the ma- 
jority of cases begins before the twentieth year. The 
ulcerating syphilide is rapidly destructive and is rarely 
found before adult life. A case in which the ulcerating 
syphilide occurs will often show other manifestations of 
syphilis, or relics of the same. Thus, glandular enlarge- 
ments, scars of the genitals or of the mucous membrane 
of the mouth and throat, evidences of old iritis, in female 
patients repeated abortions, or the birth of dead chil- 
dren at term ; sometimes the pl^sical condition of the 
offspring will shed light on an obscure case. All these 
things must be borne in mind and carefully considered 
when great difficult} 7 arises in the differentiation of these 
affections. When other means fail, a specific course of 
treatment will often enable a positive diagnosis to be 
made in the course of two or three weeks. 

In leprosj' ulcerations occur which may be mistaken 



The Cutaneous Manifestations of Syphilis. 261 

for the ulcerating syphilide, but the accompanying 
s} r mptoms of that disease, already pointed out on a 
previous page, should make the diagnosis eas} r . As a 
general rule, the ulcerations in leprosy are shallower and 
less destructive than those of syphilis. 

In the neighborhood of joints the ulcerating sj-philide 
is sometimes very persistent, progressing superficially in 
a serpiginous form. This variety of syphilitic ulceration 
is not infrequently found about the shoulder and elbow. 
It resembles lupus most closely, but can generally be 
differentiated by the characters above pointed out. 

One of the most frequent seats of the ulcerating 
syphilide is the leg and thigh. When occupying the 
leg, the syphilitic ulcer presents certain characteristics 
which should render a diagnosis comparatively easy. 
An English surgeon, Mr. Maunder, I believe, has pointed 
out that syphilitic ulcers of the leg are generally mul- 
tiple and occupy the upper half of the leg, while 
traumatic or varicose ulcers are usually single and 
located near the ankle. The cause of this localization 
of varicose ulcers near the ankle has been explained by 
Mr. Hilton in his profound lectures on " Rest and Pain. 5 ' 
" The superficial and deep veins of the leg freely com- 
municate with each other in the neighborhood of the 
ankle-joint. The first two inches above that point is 
the spot where the greatest stress is laid upon these 
superficial veins ; below that point they freely commu- 
nicate, and if the blood cannot return by superficial 
veins it can do so by the deep veins, and vice versa. 
But when you reach the point where that brown patch 
of skin so often occurs in old persons — above the inner 
malleolus — the anastomoses are less free ; and this ap- 
pears to me to be the reason why ulcers from varicose 
veins occur so frequently about that neighborhood." 



262 Diseases of the Skin. 

In some cases, the clinical features of elephantiasis 
arabnin are simulated by S3 T philitic ulceration of the 
lower extremities and its consequences. In fact, in 
these cases we have, practically, the same pathological 
condition that exists in elephantiasis, namely, obstruc- 
tion and dilatation of lymph-channels, and consequent 
new formation of connective tissue. 

Prognosis of the Ulcerating Syphilide. — The prog- 
nosis of the ulcerating syphilide, if the process is unin- 
fluenced by treatment, is unfavorable. In most cases 
the ulceration does not only continue until the initial 
infiltration is destroyed, but new deposit of the morbid 
material continues at the periphery, and the ulcerative 
process is indefinitely prolonged. Appropriate thera- 
peutic measures, however, will, in the majority of cases, 
produce rapid absorption or destruction of the infiltra- 
tion and healing of the ulcer. If, therefore, a correct 
diagnosis is made, the prognosis is generally favorable. 

THE PIGMENTARY SYPHILIDE. 

[Synonyms. — Syphiloderma pigmentosum, macular 
syphilide, taches syphilitiques.] 

Pigmentation of the skin, in the course of syphilis, 
is not infrequent. Syphilographers do not agree, how- 
ever, upon the exact etiological relation in which syph- 
ilis stands to the pigmentaiy changes. Hardy, Pillon, 
Fournier, Schwimmer, Drysdale, I. E. Atkinson, and 
Duh ring are of the opinion that the lesion is a true 
syphilide. On the other hand, Zeissl, Kaposi, Taylor, 
G. H. Fox, and Hyde regard it as merely a sequence of 
a foregoing syphilide, or an evidence of syphilitic 
cachexia. My own view is in accord with that of the 
observers first cited above. I am quite sure, however, 
that the true pigmentary syphilide is rare, and that 



The Cutaneous Manifestations of Syphilis. 263 

most cases of pigmentation of the skin occurring in 
syphilitic subjects are merely consecutive to a syphilitic 
infiltration, or an expression of a cachectic condition. 

A very good account of the pigmentary syphilide 
has been given by Pi lion, who describes it as follows : 
u On the skin of the neck, which in women is so white, 
so delicate, and so free from hair, this maculated syph- 
ilitic eruption shows itself in the form of mottled 
discolorations, communicating with each other and cir- 
cumscribing healthy spaces, the whiteness of which is 
brought out in such bold relief as to lead one at first to 
believe that these white spaces are the seat of the dis- 
ease, and to give them the appearance of patches of 
leucoderma. This mottling, without elevation above 
the surface — of an ochre or coffee-and-milk color — is 
neither painful nor itchy, and it may be present without 
being discovered. There is neither desquamation nor 
eruption ; the edges are uneven and ill-defined, and 
gradually fade away into the intermediate normal- 
colored spaces. Meeting and uniting at other points, 
the pigmented lines constitute a kind of net-work, 
inclosing in its meshes the white spots above men- 
tioned." 

The pigmentary syphilide is usually localized upon 
the neck. Fournier found it twenty -nine times out of 
thirty in this locality. It may be limited to a few 
patches, or may encircle the neck like a broad collar. 
It is also found upon the limbs, and sometimes upon 
the trunk. Nearly all observers state that it is much 
more frequent in females than in males. A short defini- 
tion given by Fournier is as follows : — 

"A macular lesion of the skin, appearing in the 
secondary period of syphilis, almost exclusively occur- 
ring in women, occupying the cervical region, aprurig- 



264 Diseases of the Skin. 

inous, slow in development, and rebellious to treat- 
ment." 

Diagnosis of the Pigmentary Syphilide. — The true 
pigmentary syphilide must be differentiated from the 
pigmentation left after other syphilitic eruptions, from 
chloasma, tinea versicolor, and cachectic pigmentations. 

The pigmentation following other syphilides has 
usually a clear history of the preceding eruption, and, 
even if this be missing, the lesion is almost distinctive. 
In the erythematous and papular syphilide the neck is 
rarely the site of the eruption. Ulcerating syphilides, 
which are often followed by pigmented scars, leave such 
a decided impression that their pre-existence can be 
predicated, even if no subjective history of the case can 
be obtained. 

Chloasmata, or moth-patches, are, like the pigmentary 
S3 7 philide, almost exclusively met with in the female sex. 
They are found especially about the face, more particu- 
larly the outer limits of the brow, the cheeks, and the 
chin ; are frequently associated with uterine disease, 
have no connection with syphilis, and seldom extend to 
the neck, the place especially liable to attack by the 
pigmentary syphilide. 

Tinea versicolor presents some points of similarity 
with the pigmentary syphilide, and may readily be mis- 
taken for it. The spots and patches of tinea versicolor 
are, however, usually found upon the chest, abdomen, 
and arms, and only exceptionally — perhaps never exclu- 
sively — upon the neck. The surface is not smooth, as 
in the syphilitic discoloration, but covered with furfur- 
aceous scales, which can be easily scratched off with the 
finger-nail. Microscopic examination of these scales 
will disclose the presence of mycelium and spores of 
microsporon furfur, the parasite to which tinea versicolor 



The Cutaneous Manifestations of Syphilis. 2G5 

is due. This fungus is absent in the pigmentary syphi- 
lide. A further point of distinction is the absolute 
lack of subjective symptoms in the syphilitic stain, 
while in tinea versicolor there is often slight itching. 
Finally, appropriate parasiticide treatment will produce a 
rapid disappearance of the parasitic discoloration, while 
it will have no effect upon the pigmentary syphilide. 

Pigmentations due to various cachexia, such as the 
malarial, cancerous, or syphilitic diathesis, so called, or 
to anaemia from any cause, may be easily differentiated 
from the true pigmentary syphilide by the more or less 
general distribution of the cachectic pigmentation, the 
absence of the sharp outlines between the light and dark 
areas, and concurrent evidences of anaemia. 

Leucoderma often presents very great similarity to 
the pigmentary syphilide, but upon careful examination 
it will be found that the white patches are due to an 
absolute diminution of pigment, while in the syphilitic 
lesion the whiteness of* the spots is only relative, owing 
to the deeper pigmentation of the surrounding skin. 
Cases in which white spots of the skin follow upon the 
sites of syphilitic scars must be differentiated from both 
these affections. 

Melanoderma, occurring in the course of Addison's 
disease, is usually more pronounced in those regions 
where there is normally excess of pigment, as in the 
areolae of the nipples, on the genital organs, backs of the 
hands, etc. Later in the course of the disease the pig- 
mentation becomes uniformly diffused. In none of the 
forms of cachectic pigmentation is the neck a special 
site of predilection, as seems to be the case with the 
pigmentary sjphilide. 

Prognosis of the Pigmentary Syphilide. — Fournier 
states that the usual duration of the pigmentary syphi- 

12 M 



266 Diseases of the Skin. 

licle is much longer than that of all other syphilides. 
It may last many months, or even a year or two, with- 
out undergoing any perceptible change. The lesion 
is only annoying from its appearance. It neither 
itches nor burns, nor does it ever ulcerate and leave 
scars. 

Specific treatment seems to have no effect what- 
ever upon the continuance of the lesions, or only 
modifies them u with despairing slowness." 

SYPHILITIC ALOPECIA. 

Falling out of the hair is not mentioned as a s} r mp- 
tom of syphilis by the earliest writers upon the disease. 
The first authors who refer to it are Fracastori, Brassa- 
vola, and Falloppio, who agree in the statement that 
this symptom was first observed between 1530 and 1540. 
Not only the hair of the head, but also that of the 
beard and eyebrows fell out, which, as Brassavola says, 
li has a ridiculous effect, and raises mirth in the be- 
holders." Nicolas Massa, one of the most accurate 
observers of the sixteenth century, also wrote thus 
accurate^ of the alopecia of syphilis : "Et quoniam 
inter quam plurima morbi gallici accidentia, depila- 
tiones capillorum, barbae, aliarum partium corporis." 
Mercury was accused of causing this, as well as some 
of the other accidents .of syphilis, but Fracastori and 
other writers showed that alopecia was not confined to 
those sy pliilitics who were treated with mercury. 

Syphilitic alopecia is one of the early symptoms of 
the secondary period pf the disease. The hairs become 
dry, lose their lustre, and fall out. The degree of bald- 
ness produced is seldom great, and is never permanent. 
In many cases only a uniform thinning of the hair is 
noticeable, as new hairs grow out before the defluvium 



The Cutaneous Manifestations of Syphilis. 267 

is completed. Cases in which the hairs of the heard, 
e} T ebrows, axillae, or genital region fall out are rare. 

Sometimes the alopecia is accompanied by and prob- 
ably, to some extent, dependent upon seborrhoea of the 
scalp. In other cases the hair falls out in patches, 
which, if closely examined, are found to be scaly and 
reddened. These are patches of the erythematous 
syphilide, and the hair falls probably in consequence of 
the local morbid process. 

The cause of the syphilitic alopecia, unaccompanied 
by seborrhoea or inflammation, is rather difficult to ex- 
plain. We can only assume that the specific virus pro- 
duces some changes in the nutrition of the hair, which 
result in atrophy. Some authors claim that the general 
impoverishment of the blood in syphilis is sufficient to 
account for this defective nutrition, but it seems to me 
that this would not account for it. In other diseases 
(non-specific in nature), even greater impoverishment 
occurs without producing the same effect upon the hair. 
^Fournier describes four degrees of S3'philitic alope- 
cia, but this seems to me an unnecessar}- refinement. 

Diagnosis of Syphilitic Alopecia. — The diagnosis 
between syphilitic alopecia and alopecia areata is not 
difficult. In the latter the hair falls out suddenly, 
and perfectly bare and white patches, with no scales, 
broken hairs, or pustules, are seen. In sj^philitic alope- 
cia the fall of hair is more gradual ; it is rarely circum- 
scribed, as in alopecia areata, and, if erythematous 
patches on the scalp become denuded, there is usually a 
reddened base, covered with scales. 

The baldness produced by tinea tonsurans is gener- 
ally easily recognized Iry its scaly base, papulo-pustnlar 
border, and the broken, " stubbly " condition of many 
of the hairs on the affected patch and vicinity. 



268 Diseases of the Skin. 

The prognosis of S3^philitie alopecia is favorable. In 
some cases, however, where the hair falls out, in conse- 
quence of suppuration or ulcerative destruction of the 
hair-papillae, regeneration of 'the hairs can, of course, not 
be expected ; but these cases cannot properly be included 
under the designation of syphilitic alopecia. 

SYPHILITIC DISEASES OF THE NAJLS. 

Brassavola mentions diseases of the nails (ungiarola) 
as a manifestation of syphilis. Two affections are 
described by authors, — one affecting the nails proper 
(onychia) and a second attacking the periungual tissues 
(paronychia, or perionychia). 

In the first variety there is morbid brittleness, par- 
tial or complete separation, and lrypertrophy of the nail. 
The diseased portion of the nail is gradually pushed 
forward by the new growth of ungual substance from 
the matrix, and a new, perfectly or imperfectly formed 
nail takes the place of the diseased one. This process 
is usually without pain or other subjective symptoms. 

In syphilitic paronychia, the seat of the disease is in 
the soft tissues under or around the nail. It may be 
simply a papular syphilide localized about the nail, or a 
gummatous infiltration, which often undergoes ulceration. 
This form is painful and obstinate. When it affects the 
toes, it often interferes, to a great degree, with locomotion. 

Treatment of the Syphilides. 

The treatment of the syphilides comprises both 
general treatment and local management. In most of 
the text-books the latter is considered of subsidiary im- 
portance, but I regard it as deserving almost as much 
attention as the treatment of the general condition. No 
one who has had any experience in the treatment of 



The Cutaneous Manifestations of Syphilis. 269 

venereal diseases can fail to appreciate the advantage 
of promoting the disappearance of an eruption upon 
the exposed portions of the body, as the face and hands, 
while it is notorious that many of the later manifesta- 
tions of the syphilitic virus can only be cured by ap- 
propriate topical treatment. 

I. GENERAL TREATMENT. 

Naturally, the first point to consider is the general 
specific treatment. As regards the time when this 
should be begun, I am decidedly of the opinion that it 
should be systematically instituted so soon as a positive 
diagnosis is made. I can see no advantage in delaying 
specific medication until constitutional symptoms make 
their appearance. Cases may sometimes present them- 
selves in which it is better to begin specific treatment, 
even if the diagnosis is somewhat in -doubt. I hold it 
of more importance to cure the patient than to make a 
faultless diagnosis. 

In the early stage of syphilis — that is, within six 
months after the appearance of the initial lesion — the 
remedy above all others is mercury. At this period 
the iodides are of little value, and had better be omitted. 
During the later manifestations of the secondary stage 
the " mixed treatment '" (mercury and iodides combined) 
finds its most effective application, while in the so-called 
tertiary stage the main reliance must be placed upon 
the iodides. 

The methods of administering mercury are various. 
Probably the most frequent way of giving it is by the 
mouth. Other methods are inunction, fumigation, and 
li t ypodermatic injection. Each of these methods has 
strong advocates, but in general practice it is often 
inconvenient to use any but the first named. 



270 Diseases of the Skin. 

In giving mere my per os any of the preparations 
employed for internal use may be administered. Many 
practitioners use blue mass; others, calomel; others, 
again, the iodides, mercury with chalk, bichloride; and, 
recently, Lustgarten has advocated the tannate, " hy- 
drargyrum tannicum oxydulatum." In using those 
preparations which are liable to prove irritating to the 
intestinal canal, the mercurial is generally combined 
with some corrective, which may, in some cases, add to 
its effect. It must not be forgotten that the prolonged 
use of mercury and the iodides, in large doses, results 
in depravation of the blood, and that haematic tonics are 
indicated in combination with the specific remedies. 

The following are some of the most efficient formulae 
used in the internal administration of mercury in 
syphilis : — 

ty. Massae hydrarg., .... gr. xl (2.6). 

Ferri sulph. exsic, .... gr. xx (1.3). 

Ext. opii, gr. v ( .3). 

M. ft. pil. no. xx. S. : One pill two or three times a day. 

^ Massae hydrarg., . . . . gr. xx (1.3). 

Hydrarg. chlor. mit., . . . gr. x ( .6). 
Hydrarg. c. cretoe, . . . . gr. xx (1.3). 

Ext. opii, . . . . . . gr. v ( .3). 

M. ft. pil. no. xx. S. : One pill twice a day. 
The calomel may be given combined with opium, as 
follows : — 

fy Hydrarg. chlor. mit., 

G. opii, aa gr. xij (.8). 

M. ft. pil. no. xxiv. S. : One pill three times a day. 
The effect of this must be carefully watched, as it 
rapidly produces the constitutional manifestations of 
the drug. 

Bnmstead recommends gray powder with quinine, as 
in the folio win o; formula : — 



The Cutaneous Manifestations of Syphilis. 271 

I£ Hydrarg. c. cretae, . . . . gr. xl (2.6). 
Quiiiinae sulphatis, .... gr. xx (1.3). 
M. ft. pil. no. xx. S. : One pill three times a day. 

Plummer's pill (Pil. antimonii co., U. S. P.) is also an 
efficient combination. 

The bichloride may be administered either in pill or 
solution. Dupuytren's pills have long been held in high 
esteem. They are composed as follows : — 

I£ Hydrarg. bichlor., .... gr. ij (.13). 

Extr. opii, gr. iij (.20). 

Extr. guaiaci, gr. xij (.80). 

M. ft. pil. no. xij. S. : One pill twice a day. 
The granules and tablet triturates of this salt, made 
by many of the manufacturing druggists, may also be 
used. The dose, to begin with, should not be over one- 
sixteenth of a grain (.004), and it should always be 
taken with, or immediately after, a meal. 

The bichloride is, however, more frequently given in 
solution, as its irritant effects upon the gastro-intestinal 
mucous membrane can be better diminished by diluting 
it until it no longer irritates. The oldest formula of 
this kind is Van Swieten's liquor : — 

^ Hydrarg. bichlor., . . . gr. j ( .065). 
Sp. vini rectif., . . . . 3ij ( 8. ). 
Aquae, . . . q. s. ft. gij (60. ). 

M. S. : Teaspoon ful in water, after meals. 
Bumstead gives this formula, which is often more 
agreeable than the plain solution : — 
1^ Hydrarg. bichlor., 

Ammonii chloridi, . . aa gr. iij ( .20). 
Tr. einehonae co , 

Aquae, . . . . aa giij (90. ). 

M. S. : Teaspoonful to a tablespoonful three times a day. 
The bichloride may also be combined with iron, as 
in the following prescription : — 



272 Diseases of the Skin. 

R Hydrarg. bichlor., . . . gr. ij ( .13). 

Tr. ferri chlor., .... §ss (16. ). 

Syrupi limonis, .... giiss (76. ). 
M. S. : Teaspoonful in water, after meals. 

Or this formula may be employed : — 

I£ Hydrarg. bichlor., . . . gr. j ( .065). 

Tr. ferri chloridi, . . . . 3iij ( 12. ). 

Sp. chloroformi, . . . . §ss ( 16. ). 

Aquae, . . . . q. s. ft. giv (120. ). 

M. S. : Dessertspoonful three times a day in sweetened water. 

Many syphilographers give one of the iodides of 
mercury from the beginning. The mercurous iodide 
(green iodide, protiodide) is the salt usually employed, 
as the mercuric or red iodide is much more irritant to 
the stomach and bowels. It is frequently combined 
with lactucarium or opium to diminish its irritant 
qualities. Piffard recommends these prescriptions : — 

fy Hydrarg. iodidi viridis, . . . gr. xv (1.). 
Ext. lactucarii, . . . . 3j (4.). 
M. ft. pil. no. c. S. : One or two pills three times a day. 

I£ Hydrarg. iodidi viridis, . . . gr. xv ( 1.). 
Pulv. ipecac, co., . . . . gr. cxl (10.). 
M. ft. chart, no. c. S. : One or two powders, after meals. 

Zeissl gives the remedy in this combination : — 

fy. Hydrarg. iodidi viridis, . . . gr. x ( .65). 
Ext. lactucarii, . . . . gr. xv (1. ). 

Gummi opii, gr. iij ( .20). 

M. ft. pil. no. xxx. S. : One morning and night, after meals. 

The tablet triturates of the protiodide may also be 
ordered. Those containing fractional dos^s (j^q-^ 
grain) are especially useful, as the dose can be regu- 
lated with the greatest nicety. 

In the later secondary and early tertiary forms of 
eruption, especially the pustular and tubercular syphi- 



The Cutaneous Manifestations of Syphilis. 273 

lides, the mixed treatment is particularly applicable. 
The bichloride and biniodide of mercury are given in 
combination with one of the alkaline iodides. 
A frequent combination is this : — 

^ Hydrarg. bichloridi, . . . gr. ij ( .13). 

Potassii iodidi, . . . . 3 ij ( 8. ). 

Aquae, §iij (96. ). 

M. S. : Teaspoon ful in water, after meals. 

The mercuric or red iodide is often used with the 
iodide of potassium as in this formula, which is very 
popular in France, where it is prescribed under the 
name of Gibert's sj'rup : — 

I£ Hydrarg. iodidi rubri, . . . gr. j ( .065). 
Potassii iodidi, 

Aquae, aa 3j ( 4, ), 

Syr. simplicis, . . . . Jv (160. ). 

M. S. : Tablespoonful three times a day. 

Or this prescription of Langston Parker may be 
used : — 

^ Hydrarg. iodidi rubri, . . . gr. iij ( .20) 
Potassii iodidi, . . . . 3j ( 4. ) 
Sp. vini rectif , . . . . 3j ( 4. ) 

Syr. zingiber, 3iij (12. ) 

Aquae, giss (48. ) 

M. S. : Twenty to thirty drops after meals. 

The tannate of mercury, introduced by Lustgarten, is 
given in pill form in doses of one grain (.065), of which 
from three to five may be given a day. The carbolate of 
mercuiy has also been used by some observers, the dose 
being one-eighth of a grain (.008) three times daily. 

The disturbances of digestion produced in many in- 
dividuals by nearly all forms of mercuiy when given by 
the mouth has led many physicians to follow the prac- 
tice of von Sigmund, the great leader of the Vienna 

12* 



274 Diseases of the Skin. 

school of syphilographers, in the use of the inunction 
treatment. It may be mentioned, however, that the inunc- 
tion treatment was not original with the Viennese syphi- 
lographer, but was practiced by laymen and physicians 
shortly after the violent epidemic outbreak of sj T philis 
at the end of the fifteenth century. Griinpeck and 
Weidmann were among the first to recommend the nse 
of mercurial ointments in the treatment of the disease. 
However, the opposition of Brant, Shellig, Ulrich von 
Hutten, Giovio, and others, brought the inunction 
treatment into disrepute until it was resuscitated by 
Louvrier and Rust at the beginning of the present 
century* 

At the present day the inunction cure is the favorite 
plan of treatment with most experienced syphilogra- 
phers. The ordinary mercurial ointment of the United 
States Pharmacopoeia is usually employed, although 
some prefer the oleate, and Lang has recently recom- 
mended a preparation which he calls u oleum cinereum." 
This is a sort of fluid mercurial ointment, made by 
triturating mercury with lard and oil. It contains 20 
per cent, of mercury. 

The following succinct directions for the application 
of the inunction treatment are quoted from Bu instead 
and Taylor 1 : — 

u Before commencing the treatment take a hot bath 
and cleanse the skin thoroughly with soap. 

u The evening, before retiring, is the most favorable 
time for the application, when a piece of the ointment 
about the size of the terminal joint of the forefinger is 
to be rubbed, with the palm of the hand, into some 
portion of the body or extremities for about fifteen 
minutes. 

1 Venereal Diseases, fifth edition, p. 861. 



The Cutaneous Manifestations of Syphilis. 2T5 

" At each application a fresh surface should be 
selected, so as to avoid irritation from excessive friction 
of any one portion. 

u An}^ of the ointment which remains after the rub- 
bing should be left upon the skin, and not washed off; 
and the patient should wear the same flannel or merino 
under-clothes constantly night and day. The following 
order may be followed in the applications : — 

" First evening, to the buttocks. 

M Second evening, to the thighs, but not near the 
groins or scrotum. 

" Third evening, to the sides of the chest, but not in 
the armpits. 

" Fourth evening, to the internal surface of the arm 
and forearm. 

"Fifth evening, to the back or belly. The former 
application is best made by an assistant, whose hand is 
protected by a glove. 

" Sixth evening, omit the application. 

" Seventh day^ take a bath in the morning, change 
under-clothes, and in the evening resume the applications 
as above." 

" Keep the mouth and teeth clean by the use of a 
brush and an astringent lotion, and the bowels open. 
If an y symptoms of salivation occur, such as increased 
flow of saliva, tenderness or swelling of the gums, fcetor 
of the breath, etc., the applications should be suspended 
and the body cleansed with soap and water." 

Hebra, in 1860, and Scarenzio, in 1864, used mer- 
curial preparations, by the hypodermatic method, in the 
general treatment of syphilis. Ambrosoli, Berkeley 
Hill, and Bergh practiced this method ; but G. Lewin, 
of Berlin, gave the subject especial attention, and, by 
his thorough and accurate researches, placed the hypo- 



216 Diseases of the Skin. 

dermatic injection of mercurials among the recognized 
methods of treatment. The preparations used are very 
multiform. Hebra, Lewin, and others used the bichlo- 
ride in solution ; Scarenzio employed calomel, suspended 
in gum-water or glycerin; and, more recently, the 
albuminate, peptonate, formidate, bicyanide, biniodide, 
and nitrate have been employed. At present, calomel 
and yellow oxide, suspended in fluid vaselin, are used 
in two of the hospitals of Paris. In this country the 
method has a strong advocate in Shoemaker, of Phila- 
delphia. The advantages claimed for it are : that it 
shortens the treatment, that it is cleanly, that it does 
not disarrange digestion, that the effects of mercury 
upon the gums are rarely manifested, that the amount 
of mercury introduced into the system can be more 
accurately measured, and that the patient can be kept 
under better control of the physician. Each dose must 
be administered by the latter. These claims are all 
prett}^ strongly indorsed by the advocates of the h} T po- 
dermatic method, and most of them seem to be ad- 
mitted. But, unfortunately, a method of so much 
promise has strong disadvantages, which militate against 
its general adoption. The injections are painful; they 
often leave inflammatory indurations, and not rarely 
abscesses. The treatment is not so uniformly success- 
ful as some have claimed, and the painful character of 
the injections causes dissatisfaction and complaint on 
the part of the patients. On the whole, the advantages 
of the method, great as the} r are, do not sufficiently 
outweigh its disadvantages. The preparations most 
frequently used for hypodermatic injection are the 
bichloride and calomel. Auspitz used the following 
formula : — 



The Cutaneous Manifestations of Syphilis. 217 

ty Hydrarg. bichloridi, . . . gr. xv ( 1.). 

Sodii chloridi, 3ss ( 2.). 

Aquae destill., §iij (96.). 

M. S. : Fifteen drops to be injected every other day. 

At the Lourcine Hospital, in Paris, Dr. Balzer em- 
ploys the following: — 

I£ Hydrarg. chlor. mit., . . . gr. v ( .30). 

Vaseliniliq., §j (32. ). 

M. S. : Fifteen minims (1.) to be injected into the buttocks 
every two or three weeks. 

Abscesses occurred in about 12 per cent, of cases. 

Dr. DuCastel, of the Hopital clu Midi, employs the 
yellow oxide of mercury suspended in the same men- 
struum. The abscesses seem to be less frequent after 
the use of this preparation than when calomel is used. 
When hypodermatic injections are employed, it is im- 
portant to observe the precaution to inject deeply, 
avoiding blood-vessels and organs that might be seriously 
damaged by the puncture or the possible subsequent 
inflammation. 

The pain of the injections can be lessened by the 
addition of cocaine to the injection. A formula pro- 
posed by Dr. Mandelbaum is as follows : — # 

ty Hydrarg. bicyanidi, . . . . gr. j ( .065). 

Cocaini hydrochlorat., . . . gr. v ( .3 ). 

Aquae destillatae, .... 3iss (6. ). 
M. S. : Fifteen drops as an injection. 

By the observance of antiseptic precautions, the 
formation of abscesses could, doubtless, often be pre- 
vented. 

The treatment of s} T philis by fumigations, as extolled 
and practiced by Langston Parker and Henry Lee, is 
not often emploj-ed in this coimtry. Yarious forms of 
fumigating apparatus are sold by the surgical-instrument 



278 Diseases of the Skin. 

makers, but a heated brick and a pail of water placed 
under a chair answer nearly as well as the most elab- 
orate lamp or gas-fixture. A half-drachm of calomel is 
placed upon the hot brick, and the patient, divested of 
his clothing and enveloped in a blanket, takes a seat 
upon the chair. The mixed vapor of calomel and steam 
should be inhaled part of the time. It is probable that 
most of the effect of the mercurial is produced by that 
inhaled, and that very little is absorbed by the skin. 
It is important, however, that the mercurial vapor be 
mixed with the vapor of water if inhaled, otherwise it is 
likel} 7 to produce irritation of the lungs. Care must 
also be taken to have pure re-sublimed calomel. 

After the fumigation, the patient wraps the blanket 
about him and goes to bed. The sublimed calomel, 
which has been deposited on the skin in a fine powder, 
should not be wiped off. 

A method of treatment, which is sometimes useful 
on account of its local effect, is that by sublimate baths. 
These were first used by Baume, in 1760. 

About half an ounce of the bichloride, with an equal 
quantity of chloride of ammonium, is dissolved in six 
ounces of water and added to a bath of thirty gallons, 
at a temperature of from 90° to 95° F. The patient 
remains in the bath from an hour to an hour and a half. 
The method is especially useful in ulcerating and bullous 
lesions, and is, perhaps, more frequently emploj^ed in 
children than in adults. 

Absorption through the skin is so irregular, how- 
ever, that the mercurial bath is an unsatisfactory 
method of treatment. In some cases the effects of the 
agent upon the gums are promptly manifested, while in 
others a prolonged nse of the baths is necessaiy before 
any results are obtained. 



The Cutaneous Manifestations of Syphilis. 279 

As accessory agents to the mercurial treatment, hot- 
air and simple water baths are very useful. It is prob- 
able that the good effects of the various popular thermae 
— such as the Hot Springs of Arkansas, in this coun- 
try, and of Aix-kvChapelle, in Europe — are largely, 
if not entirely, due to their use as adjuvants, and not 
as principal remedies. It is well known that the 
methods of treatment of syphilis at the places men- 
tioned comprise the most thorough mercurialization of 
the patients. 

In the gummatous or tertiary stage of syphilis, while 
mercury is still useful, the main reliance must be placed 
upon iodine compounds. Although the iodides of so- 
dium and ammonium are used to some extent, the 
potassium salt is the one most frequently employed. 
These preparations must always be well diluted, in order 
to avoid irritation of the stomach. The usual dose is 
five to ten grains three times a day, but, in certain 
cases, where a rapid impression is desired, from twenty 
to forty grains may be given every four hours. One of 
the best vehicles for the administration of the iodide is 
milk. It covers the taste pretty well, and prevents 
irritation of the stomach. The following is a convenient 
formula : — 

I£ Potassii iodidi, . . . . . § ss (16. )• 

Aquae, . . . . q. s. ft. §j (32.). 

M. S. : Twenty drops (equivalent to ten grains) [.7] in milk 
three or four times a day. 

Sometimes an aromatic or a bitter tonic are com- 
bined with the iodide as in these prescriptions : — 

Vf. Potassii vel sodii iodidi, . . . 3ij ( 8.). 

Aquae cinnamomi, 

Syrupi, aa §iij (96.). 

M. S. : Tablespoonful three times a day. 



280 Diseases of the Skin. 

^ Potassii iodidi, 3j ( 4.). 

Tr. gentianse co., 

Aquae, aa §iss (48.). 

M. S. : Dessertspoonful three times- a day. 

A favorite addition to prescriptions containing iodide 
of potassium is sarsaparilla or one or more of the vege- 
table alteratives. By some practitioners the latter rem- 
edies are alone used in the later stages of the disease, 
but most physicians use them in combination with the 
iodides and sometimes, also, with mercury. A prescrip- 
tion which I have frequently employed, and apparently 
with more benefit than the simple solution of iodide of 
potassium, is the following : — 

ty Hydrarg. biehloridi, . . . gr. ij ( .13). 

Potassii iodidi, §ss (16. ). 

Syr. sarsaparillae co., . . . §vj (192. ). 
M. S. : Dessertspoonful three times a day, after meals. 

A considerable number of quack nostrums against 
syphilis have as their active ingredients mercury, iodide 
of potassium, and some of the vegetable alteratives. 

During the last five years a combination of vegetable 
alteratives, known as u McDade's Formula," has been 
largely used, principally on the recommendation of the 
late Dr. J. Marion Sims. The original formula con- 
sisted of a decoction, but the following is said to be also 
eifective : — 

I£ Ex^. sarsaparillae fl., 
Ext. stillingiae fl., 
Ext. lappae minor fl., 

Ext. phytolaccae fl., . . . aa §ij (64.). 
Tr. xanthoxyli carol., . §j (32.). 

M. S. : A teaspoouful to a tablespoonful three times a day, in 
water, before meals. 

Under the name of Syrupus Trifolii Comp., Messrs. 
Parke, Davis & Co. have introduced a preparation con- 



The Cutaneous Manifestations of Syphilis. 281 

taining tri folium pratensis, stillingia sylvatica, lappa 
officinalis, phytolacca decandra, berberis aqui folium, 
caseara amarga, and xantlioxylum American urn, with 
eight grains (.52) of potassium iodide in each fluid- 
ounce (32.). I have used the formula with good effect 
in some cases, but the close, to be effective, should 
be at least half an ounce (16.) three to four times a 
day. 

One of the old alterative prescriptions is that known 
as "Zittmann's Decoction." It is largely used in Vienna, 
and, it is said, with excellent results. Two preparations 
are used, — the stronger and the weaker. The stronger 
decoction contains calomel and cinnabar, while the 
weaker contains only vegetable alteratives and aromat- 
ics. One pint of each is to be taken in the course of 
twenty -four hours. 

Other methods of treatment, as that by iodoform, 
nitric acid, gold, potassium bichromate, and tayuya, 
have not fulfilled the promises made in their favor by 
certain writers. The favorable reports of potassium 
bichromate by Giintz should stimulate further exper- 
iment with this remedy. The tablet triturates made by 
the manufacturing druggists ought to be a good form 
for administration. It is extremely liable to derange 
the stomach, and should hence be given in minute doses. 
One tablet containing ^ gr. (.001) could be safely given 
every two hours, and gradually increased to two or 
three tablets at the same interval. 

The most carefully conducted medicinal treatment is 
likely to fail of its best results if hygienic measures are 
neglected. The syphilitic patient should be w r ell fed, 
and guarded against undue exposure or overwork. His 
skin should be kept clean and active by baths. The 
clothing should be appropriate to the season, and 

M 2 



282 Diseases of the Skin. 

especial attention should be paid to the toilet of the 
teeth. Special tonic medication will often be necessary, 
— not only to counteract the depression due to the 
syphilitic virus, but the spoliative effects of certain 
remedies, such as mercury and the iodides in large 
doses. Iron, codliver-oil, and preparations of hj^po- 
phosphites, are often required to keep up the strength 
of the system. 

Duration of General Treatment. — In nearly all dis- 
eases coming under the notice of the physician, the 
special treatment is discontinued when the manifesta- 
tions against which the treatment is directed have 
disappeared. In syphilis, on the contrary, a large pro- 
portion of practitioners recommend that treatment be 
continued for a term of months or 3 T ears, irrespective of 
the presence or absence of lesions indicating the continu- 
ance of the malady. The reason given for this is that 
the disease may be present in a " latent " form, without 
giving rise to symptoms. In the present state of knowl- 
edge concerning the pathology of syphilis any specula- 
tions upon this subject would be premature in these 
pages. As the result of observation, however, most 
syphilographers are agreed upon the necessity, or ad- 
visability, at least, of prolonging the specific treatment 
of syphilis, either continuously or with occasional 
breaks, for two or three years, in order to completely 
cure the disease and prevent its subsequent recurrence. 
The plan of treatment which finds most favor at present 
is that developed by Dr. E. L. Keyes, of New York, 
and which is generally known as " the tonic treatment 
of syphilis by mercury." Dr. Ke} 7 es first finds bj T ex- 
periment what he calls the " full dose " of mercury which 
the patient will stand, and then diminishes this to one- 
half or one-third, which constitutes the " tonic dose." 



The Cutaneous Manifestations of Syphilis, 283 

To ascertain the " full close," lie begins with a small dose 
of the mercurial, — say \ grain (.01) of the green iodide, 
— and increases this very gradually until some effect is 
noticed upon the gums. When the "tonic dose" is 
established, this is continued uninterruptedly for three 
years or more. After this time the syphilis can usually 
be pronounced cured, although even then relapses some- 
times occur. Under the influence of these minute doses 
of mercury the red corpuscles of the blood increase and 
the patient's general condition improves. Mild outbreaks 
of syphilitic symptoms sometimes occur, but the latter 
usually disappear under the continuance of the "tonic 
dose," or, if the physician thinks best, the " full dose" 
may be resumed until the manifestations disappear, 
when the u tonic dose " is again taken up and proceeded 
with. In case of gummatous lesions, iodide of potas- 
sium may be given alone, or side by side with the "tonic 
dose" of mercurial. 

The intermittent plan of treatment consists in giving 
moderate doses of mercury for a time — say a month or 
two after the disappearance of active symptoms — and 
then intermitting for two to four weeks, during which 
iodine or tonics may be given. This course is recom- 
mended by such eminent syphilographers as Fournier 
and Taylor, but, in my experience, both of the methods 
here sketched are difficult to carry out. Few patients 
will persist in the use of medicines when they can see no 
use for it, and the general treatment in nearly all cases 
resolves itself into the treatment of individual out- 
breaks. Where the full co-operation of the patient can 
be obtained, the continuous administration of small 
doses — the Ke} f es plan — is rational, but I am confident 
the instructions of the physician will be obeyed in only 
a small minority of cases. 



284 Diseases of the Skin. 

Salivation should be avoided, if possible, in the 
treatment of syphilis. However, in spite of every care, 
it sometimes occurs. Prophylactically, the teeth should 
be thoroughly cleansed several times a da} 7 , especially 
following meals, and any defects in the teeth should 
receive the attention of the dentist. When salivation 
occurs, the internal use of chlorate of potassium should 
be at once resorted to. I am accustomed to combine it 
with bicarbonate of soda, and think better results are 
obtained than when the chlorate is used alone. 

If the salivary secretion is very free, the use of bel- 
ladonna is rationally indicated. 

As a mouthwash I have found the following very 
efficient and pleasant : — 

^ Acidi carbolici puri, . . . . 3ij ( 8.). 
Glyceriiri, 

Tr. kramerise, . . . . aa §j (32.). 
M. S. : A teaspoouful in a wineglassful of water as a mouth-wash. 

A 2- to 3-per-cent. solution of acetate of alumina is 
also a very efficient niouth-wash. A dilution of fluid 
extract of lrydrastis may be used for the same purpose. 

IT. LOCAL TREATMENT. 

In the erythematous syphilide, especially when it 
occurs on the scalp and face, the application of calomel 
or ammoniated mercury ointment often hastens the dis- 
appearance of the eruption. The following is especially 
useful when the eruption is localized about the angles 
between the nose and cheeks : — 

5 Hydrarg. ammoniat., . . gr. xx ( 1.3). 

Glyceriti amyli, . . . . §j (32. ). 

M. ft. pasta. 

When localized in the palms, the same application, 
or a 1- to 2-per-cent. red oxide-of-mercuiy ointment 
should be applied at night, and leather gloves worn. 



The Cutaneous Manifestations of Syphilis. 285 

For the balanitis which sometimes occurs as a con- 
sequence of the erythematous eruption upon the glans, 
a weak bichloride solution (1 to 2000) may be applied, 
or the following may be painted on with a camel's hair 
pencil once daily : — 

ty Hydrarg. bichlor., . . . gr. ij ( .13). 
Alcoholis, §j (32. ).— M. 

The same application is useful in erythematous vul- 
vitis, and in the red or grayish patches occurring on the 
tongue in syphilitic subjects. 

Corrosive-sublimate baths (Ji-iv [4.-16.] to each 
bath) may also be used when the erythematous eruption 
is general. 

In the papular syphilide of the face and forehead I 
have found the white-precipitate ointment promptly 
effective. Where an ointment is objectionable, the fol- 
lowing lotion renders good service : — 

fy Hydrarg. bichloridi, . . . gr. iv ( .25). 

Glycerini, 3j ( 4. ). 

Sp. vini rectif., . . . §j (32. ). 

Aquse aurantii flor., . . . §iij (96. ). — M. 

Dry, scaly papules of the palms and soles yield most 
rapidly to mercurial ointment, applied at night after 
soaking the hands and feet in hot water for ten or fif- 
teen minutes. During the day the above bichloride 
lotion, or the glycerite of starch and white precipitate, 
may be used. If there is much infiltration, it is neces- 
sary to destro\ r the superficial epidermic layer with a 
strong solution of caustic potash (3ss to §j) [1 to 16]. 
This is mopped on and immediately washed off with 
warm water, after which one of the above-mentioned 
mercurial ointments may be applied. Sometimes an 
ointment of salicylic acid (3 to 5 per cent.) alone, or 



286 Diseases of the Skin. 

combined with resorcin (-4 per cent.), or white precipi- 
tate, answers better. 

For moist papules, Zeissl recommends careful cleans- 
ing with warm water, then applications of salt water 
and dusting with calomel. Ricord advises solution of 
chlorinated soda, followed by calomel-powder. In many 
cases, dusting the lesions with calomel and keeping 
them dry, and preventing friction by covering them 
with absorbent cotton, will produce a rapid cure. The 
importance of cleanliness in this form of syphilitic 
eruption cannot be overestimated. The offensive odor 
is best destroyed by frequent washing with dilute liquor 
sodse chlorinatae (1 to 10;. The late M. Victor de 
Meric used the following with good effect : — 

^ Hydrarg. chlor. mitis, 

Pulv. zinci oxidi, . . . aa 3ij ( 8.). 

Ungt, simplicis, gj (32.). 

M. ft. ungt. S. : Apply three or four times a day. 

Lang uses a dusting-powder of salicylic acid and 
pulverized starch, as follows : — 

R Acidi salieyliei, . . . . gr. xx ( 1.3). 
Pulv. amyli, . gj (32. ).— M. 

The salicylic acid should be in the form of an 
impalpable powder, otherwise it causes considerable 
pain. 

The pustular syphilide. if the pustules are unbroken, 
is benefited by sublimate baths. If there are small 
ulcers, covered with crusts and scabs, the latter should 
be softened and removed by the aid of a warm bath, and 
the lesions dusted witli calomel, oxide of zinc, bismuth, 
or starch Calomel ointment (5 to 10 per cent.) is also 
useful. If the remaining ulcers are slow to heal, they 
magi be touched with solid nitrate of silver or tincture 



The Cutaneous Manifestations of Syphilis. 287 

of iodine, and then covered with calomel ointment, or 
thinly-spread mercurial plaster. 

For the small, pustular syphilide of the scalp Taylor 
recommends : — 

I£ Ungt. hydrarg. nitrat., . . . 3ij ( 8.). 

Petrolati, ?j (32.). 

M. ft. ungt. S. : To be applied after shampooing. 

The following makes a more agreeable pomade : — 

I£ Ungt. hydrarg. nitrat., . . . 3ij ( 8.). 

Balsam. Peruv., 3ss ( 2.). 

Petrolati, ...... §j (32.). 

M. ft. ungt. 

The tubercular and gummatous syphilides will 
usually yield to mercurial plaster, kept constantly 
applied. Gummata often resemble abscesses and boils 
yery closely, and the temptation to plunge a bistoury 
into them with a view to evacuate the contents is 
exceedingly great. Absorption will, however, in most 
cases follow the application of mercurial plaster. In 
obstinate cases of the tubercular eruption, chrysarobin 
and salicylic acid in collodion, as in the following pre- 
scription, may be painted on once a day with a camel's 
hair pencil : — 

$ Chrysarobini, . . . . . 3ss ( 2.). 

Acidi salicylici, 3j ( 4.). 

Collodii flexilis, §iss (48.). 

M. Put a camel's hair pencil in the cork. 

In some cases, scarifications, followed by mercurial 
plaster, or destruction with the galvano-cautery or by 
electrolysis, may be desirable, in order to hasten the 
disappearance of a dense infiltration. 

Ulcerated gummata should first be cauterized with 
nitrate of silver or the galvano-cautery, or the infiltration 



288 Diseases of the Skin. 

scraped out with the curette, and then dressed with 
iodoform in powder, or the following ointment : — 

I£ Pulv. iodoformi, . . . . 3j ( 4.). 
Bals. Peruviaui, ..... 3ss (2.). 
Cerat. simplicis, . . . . §j (32.). 

M. ft. ungt. 

Lotions of carbolic acid (2 to 4 per cent.) are also 
useful. In some cases, nothing seems to answer so well 
as the simple mercurial ointment. 

Lang injects a solution of iodine into the neighbor- 
hood of large gummata, or into the infiltration itself. 
The formula he uses is as follows : — 

ty Iodiiri, gr. iij ( .2). 

Potassii iodidi, .... 3ss ( 2. ). 
Aquae destill., . . . . 3v (^20. ). 
M. S. : A few drops to be injected by means of a hypodermatic 
syringe. 

Zeissl uses the following stimulating ointment in 
ulcerating gummata : — 

5- Argenti nitrat., . . . . gr. ij ( .13). 

Balsam. Peruv., . . . . 3ss (2. ). 

Ungt. simplicis, . . . . 3ij (8. ). 
M. ft. ungt. 

Syphilitic alopecia demands some attention from the 
physician, as patients are usually extremely anxious to 
preserve their hair. When the defluvium is accompanied 
by seborrhcea, the remedies appropriate to that condi- 
tion should be used. The scalp should be shampooed 
once or twice a week with spiritus saponis kalinus of 
Hebra, followed by the alternate use of a 2-per-cent. 
solution of resorcin in baj T -rnm, and a 4- to 8-per-cent. 
white-precipitate ointment. Taylor uses the following 
hair-tonic : — 



The Cutaneous Manifestations of Syphilis. 289 

fy Tr. cantharidis, . . . . §iss ( 48.). 

Tr. capsici, 3iv ( 16.). 

01. ricini, §iss ( 48.). 

Alcoholis, . . . q. s. ft. gviij (256.). 

01. neroli, q. s. to perfume. 

M. S. : Use once a day. Cutting the hair is unnecessary. 

Onychia is best treated with a non-irritating mercu- 
rial ointment, which can be kept in contact with the 
diseased nail all the time. The glycerite of starch and 
calomel and oleate of mercury (2 to 4 per cent.) are good 
applications. In paronychia due to syphilis the fingers 
should first be immersed in hot water for ten or fifteen 
minutes, and afterward enveloped in mercurial ointment 
or mercurial plaster. When there is much pain, inflam- 
mation, or ulceration, painting with solution of nitrate 
of silver, tincture of iodine, and afterward dressing 
with iodoform and enveloping in mercurial plaster may 
give good results. Sometimes it is necessary to trim 
the nail so that the applications can be made directly to 
the. seat of the infiltration. Corrosive-sublimate collo- 
dion (1 per cent.) is a cleanly and efficient application 
in the dry form. 

When paronychia affects the toes the nails should be 
carefully trimmed to prevent irritation and pain on 
walking. 

The dilute solution of subacetate of lead, to which 
tincture of opium has been added, will often promptly 
relieve the pain. Cocaine and belladonna ointment is 
also useful in some cases where the pain is very severe ; 
but probably no single remedy is so effective in reliev- 
ing this symptom as bathing the affected limb in hot 
water. 

13 N 



FORMULA. 



1 — R Acidi tannici, . . . . gr. viij ( 0.5). 
Sp. myrciae, . . . . giv (120. ). 
M. For hyperidrosis of the hands and axillae. 

2— R Zincioxidi, . . . . gj ( 30.). 
Pulv. amyli, . giv (120.). 

M. For hyperidrosis localis, acute vesicular eczema, herpes 
facialis, preputials, etc. 

3 — R Pulv. calaminae, . . . gij ( 8.). 
Pulv. iridis Florentinae, . . gj (30.). 
Pulv. arnyli, .... giij (90.). 
M. For hyperidrosis localis, and as a general dusting- 
powder. 

4 — R Pulv. acidi borici, . . . 5j ( 4. ). 
Pulv. cretae praecipitatae, . §iv (120. ). 

01. rosae, gtt. j ( 0.06). 

M. For hyperidrosis localis, brornidrosis, chafe, etc. 

5 — R Acidi salicylici, . . • 9U ( 3.). 

Amyli, gss (20.). 

Pulv. talci, .... giiss (87.). 
M. Used in the German army for sweating feet. 

UNGUENTUM HEBRJ1. 

6 — R Emplastr. plumbi, 

01. olivae, . . . aa giv (120.). 

M. ft. ungt, 

S. : Diachylon ointment. The most useful "stock oint- 
ment' ' in the treatment of skin diseases. 
(290) 



Formulas. 291 

UNGUENT CJM VASELINI PLUMBICUM. 

7 — R Emplastr. pluinbi, 

Vaselini, . . . . aa giv (120.). 
M. ft. ungt. 

A modification of the preceding, first suggested by Dr. H. 
G. Piffard, of New York. 

BORIC-ACID OINTMENT. 

8— R Acidi borici, . . . . 3j ( 4.). 

Glycerini, . . . . 3j ( 4.). 

Cerati simplicis, . . . ^ij (60.). 
M. ft. ungt. For bromidrosis. 

GLYCERITE OF STARCH. 

9— R Amyli, 3ij ( 8.). 

Glycerini, . . . . gij (60.). 

M. Rub together in a mortar until thoroughly mixed, and 
then heat slowly with constant stirring. 

SPIRITUS SAPONIS KALINUS. 

10 — R Saponis viridis, 

Sp. vini rectif., . . aa gij (60. ). 

01. lavandul., .... gtt. x ( 0.6). 

M. Useful as a detergent agent in many skin diseases. 

11— R Hydrarg. bicnior., . . . gr. j ( 0.06). 

Sp. vini rect., . . . . 3j ( 4. ). 

Ungt. aquae ros.se, . . gij (60. ). 
M. ft. ungt. 

12— R Hydrarg. oxid. rubr., . . gr. v ( 0.32). 
Ungt. aquae rosse, . . . gij (60. ). 
M. ft. ungt. 

13 — R Hydrarg. ammoniat., . . £>j ( 4. ). 

Tr. capsici, . . . . 3j ( 4. ). 

Vaselini, gij (60. ). 

01. bergamii, .... gtt. iv ( 0.2). 
M. ft. ungt. 



292 Formulae. 

14— R Sulplmris praecip., . . . 3j ( 4 ). 
Ungt. aquae rosae, . . . §ij (60.). 
M. ft. ungt. 

15 — R Sulphuris praecip., . . . £j ( 4. ). 

Acidi salicylici, . . . gr. xx ( 1.3). 

Vaselini, gij (60. ). 

M. ft. ungt. 

16— B 01. nisei crudi, . . . 5j (4.). 

Ungt. aquae rosae, . . . gij (60.). 
M. ft. ungt. 

17— R Ferri sulpli., 

Potassii carb., . . . . aa 3j (4.). 
M. ft. pil. no. xl. 

S. : One or two three times a day. An excellent ferruginous 
tonic. 

18 — R Liq. potassii arsenitis, 

Syrupi simplicis, . . aa 3ij ( 8.). 
Vini ferri, . . . . giss (45.). 

Aquae, §ij (60.). 

M. S. : Teaspoonful immediately before or after each 
meal. (Each teaspoonful contains nearly 4 minims of Fowler's 
solution.) 

\&— R Tr. ferri chlor., . . . gss (15.). 
Acidi phosph. dil., . . . 3ij ( 8.). 
Syrupi limonis, . q. s. ft. giij (90.). 
M. S. : Teaspoonful in water after each meal. 

20— R Tr. calumbae, 

Aquae calcis, . . aa %iv (120.). 

M. S. : Tablespoonful at meal-time. 

21— R Magnesii sulph., . . . gj (30.). 

Tr. ferri chlor., . . . 3j ( 4.). 

Aquae, . . . q. s. ft. giv (120.). 
M. S. : Tablespoonful to be taken in a tumblerful of water 
before breakfast. 



Formulae. 293 

22— R Aceti, 3ij. ( 8.). 

Glycerini, .... 3iij (12.). 
Kaolini, 3iv (16.). 

M. ft. pasta. 

23— R Pulv. amyli, . . . . Sij ( 8.). 

Ungt. aqua? rosse, . . . gj (30.). 
M. ft. ungt. 

24 — R Potassii acetat., 

Ext. taraxaci fl., . . aa §j (30.). 
Aquae, . . . q. s. ft. giij (90.). 
M. S. : Teaspoonful in a tumblerful of water three times a 
day, after meals. 

25 — R Potass sulphureti, 

Zinei sulpliatis, . . aa £ss (2.). 
Glycerini, . . . .. . 3j ( 4.). 

Aquae rosae, . q. s. ft. giij (90.). 

M. S. : Apply two or three times daily. 

26 — R Sulplmris praecip., 

Potassii carb., 

Sp. vini rectif., 

Glycerini, . . aa 3j (4.). 

M. ft. pasta. 
S. : To be applied at night in indurated acne. 

27 — R Acidi arseniosi, . . . gr. ij ( .13). 
Pulv. piperis nigr. , 

Pulv. glycyrrhizse, . . aa gr. xxxij (2. ). 
M. ft. pil. no. xxxij. 
S. : One three times a day. 

28— R Magnesii sulph., . . . gj (30.). 

Tr. ferri chlor., . . . 3iss ( 6.). 

Aqua?, . . q. s. ft. giv (120.). 

M. S. : Tablespoonful in a gobletful of water every 
morning. 



294 Formulae. 

29— R Tr. ferri chlor., . . . 3iij (12.). 
Acidi pliospli. dil., . . - 3ij ( 8.). 
Syrupi liinonis, . q. s. ft. Jjij (60.). 
M. S. : Teaspoonful in water after each meal. 

30 — R Potassii acetat., 

Ext. taraxaci fl., . aa gj (30.). 

Aquae, . . . q. s. ft. §iij (90.). 

M. S. : Teaspoonful in a tumblerful of water three times a 
day, after meals. 

lassar's paste. 
31 — R Acidi salicylici, . . e gr. x ( .65). 

Pulv. amyli, 
Zinci oxidi, . . . aa gij ( 8. ). 

Vaselini, gss (16. ). 

M. ft. ungt. 

32— R 01. rusci, 3ss ( 2.). 

Ungt. aq. rosae, . . gj (30.). 

M. ft. ungt. 

33— R Pulv. zinci oxidi, . . . 3ij ( 8.). 

Mucil. acaciae, . . . • 3j ( 4.)' 

Emuls. amygdal., . . . §ij ( 60.). 

Aquae rosae, . q. s. ft. giv (120.). 

M. S. : Apply every three or four hours. 

34 — R Hydrarg. oxidi flav., . . gr. x ( .65). 
Pulv. amyli, 

Vaselini, . . . aa gj (30. ). 

M. ft. ungt. 

LIQUOR PICIS ALKALINUS. 

35— R Picis liquidae, . gj (30.). 

Potassae causticae, . . . gss (15.). 
Aquae, . . . . giiss (75.). 

M. S. : Dissolve the potash in the water and add slowly to 
the tar, in a mortar, with friction. To be used diluted with 
1, 2, 4, or 8 parts of water. 



Formulae. 295 

36— B Hydrarg. bichlor., . . gr. iv ( .25). 
Tine, benzoini co., . . . §j (30. ). 
M. S. : Apply ^with a camel's hair pencil. 



37— B SaloL, 






^Ether., .... 


aa 


3ss (2.). 


Collodii flex., . 


ad 


3ij (8.). 


M. Paint on chapped nipples. 






38 — B Pulv. zinci oxidi, 




gss (16.). 


Pulv. caniphorae, 


. 


3iss ( 6.). 


Pulv. amyli, 


. 


Si (32.). 


M. S. : Dusting-powder. 






39— B Tr. lobeliae, 




gij (60.). 


Sodii bicarb., . 




3j ( 4.). 


Aquae, .... 




§ij (60.). 


40 — B Pulv. camphorae, 


# 


■gr. x ( .6). 


Cretae preparatae, 


. 


SJ (30. ). 


01. lini, .... 


. 


ftl (60. ). 


Bals. Peruv., . 


. 


gtt. XX ( 1. ). 


M. ft. pasta. 







41 — B Potassii acetatis, . . . gj (30.). 
Ext. fl. taraxaci, . . . §ij (60.). 
M. S. : Teaspoonful three times a day in a tumblerful of 
water. 

42— B Calcis vivae, . . . . gss ( 16.). 
Sulphuris sublim., . . . §j ( 30.). 
Aquae, gx (300.). 

Boil the mixture until it measures four fluidounces (120.), 
and filter. 

43 — B Acidi salicylici, . . . 3ss ( 2.). 
Spiriti myrciae, . . . gij (64.). 

S. : Apply night and morning with a soft rag or sponge. 



. m 


( 8.) 


■ 3j 


( 4.) 


• Sss 


( 16.) 


• 3iij 


( 12.) 


- In 


(190.) 



296 Formulae. 

44 — R Acidi salicylici, . . . 3ss ( 2.). 
Hydrarg. ammoniati, . . 3j ( 4.). 
Ungt. aquae rosae, . . . ^j (32.). 
M. ft. ungt. 
S. : Apply at night. 

45 — R Saponis viridis, . . . gij (64. ). 

Sp. vini rectificati, . . . gj (32. ). 

Hydrarg. bichloridi, . . gr. vj ( .4). 

01. lavandulas, . . . gtt. x ( .6). 

M. Solve et filtra. 
S. : Apply at night, and wash it off in the morning. 

46 — R Sodii boratis, . 
Potassii chlorat., 
Glycerini, 
Sp. vini rectif., 

Aquas rosae, . . q. s. ft, 
M. S. : Apply with a soft sponge several times a day. 

47 — R Bismuthi subnitrat., 

Hydrarg. ammoniat., . aa £j ( 4.). 

Vaselini, !§j (32.). 

M. ft. ungt. 

48 — R Aeidi salicylici, . . gr. x-xxx ( .7-2.). 
Sulplmris praecip., 
Pulv. amyli, 
Ungt. aquas rosae, 
M. ft. ungt. 

49 — R Acidi salicylici, ... gss ( 2. ). 
Ext. cannabis Indicae, . . gr. v ( .3). 
Collodii, . . . . . gij (64. ). 
M. S. : Put a small camel's hair pencil in the cork. 

50 — R Hydrarg. bichloridi, . . gr. xv ( 1.). 
Collodii flexilis, . . . §j (32.). 
M. S. : Paint on the warts once a day until they drop off. 



3ss 


( 2- 


) 


§ss 


(16. 


) 


a 


(32. 


) 



Formulae. 



297 



51 — R Adipis benzoati, 
Glycerini, 

Petrolati, .... 
M. S. : Apply after bathing. 

52 — R Potassii bicarb., 
Glycerini, 
Ungt. bisrnuthi oleatis, . 



Si ( 4.). 

m*i ( b.). 

gss (16.). 



Siij ( 12.). 
giss ( 48.). 
giv (128.).— M. 



DEPILATORIES. 



53 — B Barii sulphidi, 
Zinci oxidi, 
Coccionellae, 



5iss ( 6. ). 
3vj (24. ). 
gr.j( .065).— M. 



3ss ( 2.). 
Jss (16.). 
3« ( 3.). 



54 — B Arsenici sulphidi flavse, 
Calcis vivse, 
Farinae tritici, . 
Mix with water to form a paste, and apply with a wooden 
spatula. In three or four minutes the paste is scraped off, the 
part washed with hot water, and a dusting-powder of starch 
or oxide of zinc applied. 

55 — R Calcii hydrosulphureti, . . 3ij (8. ). 
Glyceriti amyli, 

Pulv. amyli, . . aa 3j (4. ). 

01. neroli, .... gtt. j ( .065).— M. 

This is applied in a thick layer, and washed off in ten to 
fifteen minutes with warm water. Afterward a dusting-pow- 
der should be applied. 



5Q — R Sodii boratis, . 


. £iiss ( 10.). 


Glycerini, 




Tr. benzoini, . 


aa 3j ( 4.). 


Aquae cologniensis opt., . 


. £ 8 s ( 16.). 


Aquae aurantii flor., q. i 


3. ft. gvj (192.). 



57— B Tinct. capsici, .... gss ( 16.). 
Glycerini, . 3ij ( 8.). 

Sp. myrciae, . . q. s. ft. gviij (256.). 

M. S. : To be well rubbed into the scalp nightly. 
13* 



298 



Formulae. 



58 — R Resorcini puri, 
Sp. myrciae, 

59 — R Sulphuris praecip., 
Sp. myrciae, 

60 — R Sulphuris praecip., 
Ungt. aquae rosae, 
M. ft. ungt. 

61 — R Resorcini puri, . 
Ungt. aquae rosae, 
M. ft. ungt. 

62— R Acidi salicyli, . 

Sulphuris praecip., 
Ungt. aquae rosae, 
M. ft. ungt. 

63 — R Acidi carbolici, . 
Aquae, 

64 — R Acidi salicylici, 
Acidi borici, 
Glycerini, 
Sp. vini rectif., 
Aquae, 

* 65 — R Acidi carbolici, . 
Lanolini, . 

M. ft. ungt. 

66— R Thymolis, . 

Ungt. aquae rosae, 
M. ft. ungt. 

CAMPHOR 

67 — R Campliorae, 

Chlorali hydrat , 
M. ft. solutio. 

68— R Cocaini, . . . 
Lanolini, . 
M. ft. ungt. 



3ss-j ( 2.-4.). 
gviij (256. ).~M. 

3ss ( 2.). 
gviij (256.).-M. 

3ss ( 2.). 
3J (32.)- 



gr. vx-xx ( 1.-1.3). 
Ij (32. )• 



gr. x( .7). 
3ss ( 2. ). 
Ij (32. )• 



3i-iij (4.-12.). 

Oj (500. ).— M. 



3ij 
3j 



( 8.) 



( 



8.) 
4.). 



aa gj ( 30.). 

ad gviij (250.).— M. 

. HIM -7). 

• H (32.). 

• gr.x( .7). 

• Jj (32. ). 



CHLOKAL. 

. aa 3ij (8.). 



. gr. x ( .7). 
• Ei (32. ). 



INDEX. 



Acne, 22 

causation of, 24 

treatment of, 25 
Acne rosacea?, 28 

treatment of, 29 
Ainhum, 189 
Aix-la-Chapelle, 279 
Alopecia, 163 

areata, 165 
Anaesthesia, 196 
Angioma, 192 

pigmentosum, 140 

treatment of, 193 
Angiomyoma, 190 
Anidrosis, 8 
Anthrax, 88 
Area eel si, 165 
Arsenic in eczema, 56 
Asteatosis, 22 
Atrophia cutis, 140 
Atrophies, 159 
Atrophy, cutaneous, 160 

of pigment, 161 

of the hair, 163 

of the skin, 159 

unilateral, of the face, 160 

Bacterium foetidum, 6 
Baldness, 163 
cause of, 163 
treatment of, 166 
Balzer on hypodermatic use of mer- 
cury, 277 
Body-louse, 207 
Brassavola on syphilitic alopecia, 

266 
Bromidrosis, 7, 9 

Bullous exfoliative dermatitis, 107 
Bumstead and Taylor on mercurial 

inunction, 274 
Burns, 79 

Callosities, 131 
Cancer of skin, 168 
Chloasma, 124 
Chromidrosis, 9 
Chyluria, 158 



Colored sweat, 9 

Comedo, 18 

Condylomata lata, 236 

Conical papular syphilide, 229, 230 

diagnosis of, 230 
Connective-tissue new formations, 

173 
Contagious impetigo, 113 
Corn-cures, 134 
Corns, 131 

diagnosis of, 132 

treatment of, 133 
Crab-louse, 208 
Crural eczema, 54 

Dandruff, 164 
Dermatalgia, 196 
Dermatitis calorica, 79 

exfoliativa, 104 

exfoliative, of infants, 104 

gangrenosa, 83 

herpetiformis, 96 

medicamentosa, 81 

traumatica, 77 

venenata, 78 
Disse and TaguchPs microbe of 

syphilis, 254 
Drug eruptions, 81 
Du Castel on hypodermatic use of 

mercury, 277 
Dupuytren's pills, 271 
Duration of treatment in syphilis, 
282 

Eczema, 37 
acute, 40 
chronic, 44 
diagnosis of, 54 
general considerations, 37 
local treatment of, 58 
localization of, 45 
treatment of, 56 
varieties of, 40 
of anus, 53 
of face, 46 
of joints, 53 
of legs, 54 

(299) 



300 



Index. 



Eczema of nipple, 50 

of perineum, 53 

of scalp, 45 

of the genitals, 52 

of the hands and feet, 54 

of the trunk, 49 
Ecthyma, 112 
Electrolysis in hypertrichosis, 147 

in keloid, 174 
Elephantiasis arabum,155 

graecorum, 178 
Elephant's leg, 155 
Epidermal hypertrophies, 127 
Epithelial molluscum, 130 

new formations, 168 
Epithelioma, 168 

diagnosis of, 172 
Erysipelas, 84 

causation of, 85 

treatment of, 85 
Erythema, 66 

congestive, 67 

exudative, 67 

intertrigo, 68 

multiforme, 69 

symptomatic, 67 

syphilitica, 220 

treatment of, 68 
Erythematous syphilide, 220 

diagnosis of, 224 

minute anatomy of, 228 

prognosis of, 228 
Exfoliative dermatitis, 104 

Favus, 200 
Feigwarzen, 236 
Fibroma, 174 
Fibromyoma, 190 
Filaria sanguinis hominis, 157 
Fish-skin disease, 141 
Flat papular syphilide, 231 
Flesh-worms, 19 

Fournier on the pigmentary syphi- 
lide, 263 
Freckles, 123 
Frost-bite, 80 
Furuncle, 86 

Gangrenous dermatitis, 83 
General exfoliative dermatitis, 107 
Gibert's syrup, 273 
Gonorrhoeal erythema, 226 
Giintz on potassium bichromate in 

syphilis, 281 
Gummous syphilide, 252 
Gummy tumor, 252 



Hair, hypertrophy of, 144 

Head-louse, 207 

Hebra on hypodermatic use of 

mercury, 275 
Hemorrhages of the skin, 118 
Herpes facialis, 91 

of the genitals, 91 

praeputialis, 91 

simplex, 91 

zoster, 92 

causation of, 93 
distribution of, 94 
treatment of, 95 
Herpetiform syphilide, 241 
Hide-bound skin, 152 
Hilton on location of varicose ulcers, 

261 
Hirsuties, 144 
Horns, cutaneous, 137 
Hot springs of Arkansas, 279 
Hygienic treatment in syphilis, 281 
Hyperesthesia, 196 
Hyperidrosis, 5 

treatment of, 6 
Hypertrichosis, 144 

causes of, 145 

treatment of, 147 
Hypertrophies of the skin, 123 
Hypodermatic use of mercury, 275 

Ichthyosis, 141 

treatment of, 143 
Impetigo, 112 

contagiosa, 113 
Impetiginous syphilide, 241 
Indurative oedema of infants, 154 
Inflammations of the skin, 66 
Inunction-cure for syphilis, 274 
Itch-mite, 205 

Kaposi on histology of the gummy 

nodule, 254 
Keloid, 173 
Keratosis pilaris, 129 

senilis, 127 
Kerion, 202 
Keyes on "tonic treatment" of 

syphilis, 228 

Large papular syphilide, 231 

pustular syphilide, 243 
diagnosis of, 243 
Lenticular pustular syphilide, 243 

syphilide, 231 
Lepra, 178 

syphilitica, 232 



Index. 



301 



Leprosy, 178 
anaesthetic, 180 

causes of, 181 

diagnosis of, 181 

treatment of, 181 

tubercular, 179 
Leucoderma, 161 

Lewin on hypodermatic use of mer- 
cury, 275 
Lichen, 109 

planus, 109 

ruber, 109 

scrofulosus, 110 

syphiliticus, 229 
Lipoma, 175 
Local exfoliative dermatitis, 108 

treatment of syphilides, 284 
Lupus erythematosus, 183 
diagnosis of, 185 
treatment of, 185 

vulgaris, 185 
diagnosis of, 187 
treatment of, 188 
Lustgarten's syphilis microbe, 254 
Lymphangioma, 192 
Lymphangio-myoma, 190 
Lymph-scrotum, 158 

Macula syphilitica, 220 
Macular syphilide, 220, 262 
McDade's formula, 280 
Madura foot, 190 
Malignant pustule, 90 
Mandelbaum on hypodermatic use 

of mercury, 277 
Maunder on diagnosis of ulcerating 

syphilide," 261 
Massa on syphilitic alopecia, 266 
Mercurial baths in syphilis, 278 

fumigations in syphilis, 277 
Mercury in syphilis, 269 
Microsporon furfur, 203 
Miliary syphilide, 229, 241 
Milium, 21 
Moist papular syphilide, 236 

diagnosis of, 239 
Molluscum epitheliale, 130 
Morphoea, 153 
Moth-patches, 124 
Mucous patches, localization of, 
238 

of the skin, 236 
Myoma, 190 

Nsevus, neurotic, 139 
pigmentary, 138 



Nrevus pilosus, 138 
Neuroma, 191 
Neuroses, 196 
New formations, 168 
Nodular syphilide, 252 

differential diagnosis of, 254 

minute anatomy of, 253 

prognosis of, 257 

Odorous sweat, 9 

Paget's disease, 50 
Papular syphilide, 228 

minute anatomy of, 239 

prognosis of, 240 
Papulo-granular syphilide, 229 

-squamous syphilide, 232 
Parasites, animal, 205 

vegetable, 199 
Parasitic skin diseases, 199 
Pediculosis, 206 
Pedi cuius capitis, 207 

corporis, 207 

pubis, 208 
Pemphigus, 114 

acute, 104 

diagnosis of, 115 

foliaceous, 107 

treatment of, 118 
Perforating ulcer of the foot, 191 

treatment of, 191 
Perspiration, chemistry of, 3 

secretion of, 4 
Perspiratory glands, anatomy and 

physiology of, 3 
Phlegmon, 89 
Pigmentary hypertrophies, 123 

syphilide, 262 
diagnosis of, 264 
prognosis of, 265 
Pillon on the pigmentary syphilide, 

263 
Pityriasis rubra, 107 

versicolor, 202 
Plaques muqueuses, 236 
Podelcoma, 189 
Porcupine disease, 142 
Post-infective stage of syphilis, 247 
Potassium bichromate in syphilis, 

281 J 

Prickly heat, 10 
Prurigo, 111 
Pruritus, 197 
Psoriasis, 98 

diagnosis of, 99 

treatment of, 101 



302 



Index. 



Purpura, 119 
hemorrhagica, 120 
rheuinatica, 120 
simplex, 120 
Pustula foeda ani, 236 
Pustular syphilide, 240 
in negroes, 244 
prognosis of, 245 
Pustule ortiee, 220 

Rhinoscleroma, 176 
Ringworm, 200 

diagnosis of, 202 

treatment of, 203 
Rosacea, 194 
Roseola urticata, 222 

syphilitica, 220 
Rupia, 243 

Salivation in syphilis, 284 
Sarcoma, 177 
Scabies, 205 

diagnosis of, 206 

treatment of, 206 
Scaly papular syphilide, 232 

diagnosis of, 234 
Scarenzio on hypodermatic use of 

mercury, 275 
Schleimpapeln, 236 
Sclerema neonatorum, 154 
Scleroderma, 152 
Scrofuloderma, 182 
Scurvy, 121 
Sebaceous cyst, 21 

glands, an atom v and physiology 
of, 15 
Seborrhoea, 16 

diagnosis of, 17 

oleosa, 17 

sicca, 16 

treatment of, 18 
Shingles, 92 
Shoemaker on hypodermatic use of 

mercury, 276 
Sigmund on inunction cure, 274 
Sims on McDade's formula in syphi- 
lis, 280 
Skin cancer, 168 
Small papular syphilide, 229, 241 

diagnosis of, 242 
Spiritus saponis kalinus, 18 
Squamous syphilide, 232 
Steatoma, 21 
Striae atrophica, 159 
Sudamen, 10 
Sweat, secretion of, 4 



Sweat, chemistry of, 3 

derangements of secretion of, 5 

glands, anatomy and physiology 
of, 3 
number of, 3 
Sweat-blisters, 10 
Sweating sickness, 5 
Sycosis, 30 

causation of, 31 

diagnosis of, 32 

parasitica, 202 

treatment of, 34 
Syphilide merisee, 231 
Syphilides, chronological sequence 
of, 211 

classification of, 210 

color of, 214 

configuration of, 216 

diagnostic features of, 211 

general morphology of, 210 

general treatment of, 269 

localization and distribution of, 
213 

multiformity of, 21 6 

precoces, 212 

racial peculiarities of, 217 

subjective symptoms of, 217 

tardives, 112 
Syphiloderma pigmentosum, 262 
Syphilis cutanea maculosa, 220 

in the negro, 217 

of the skin, 209 
Syphilitic acne, 241 

alopecia, 266 
diagnosis of, 267 

disease of the nails, 268 

ecthyma, 243 

eczema, 224 

gumma, 252 

impetigo, 241 

lupus, 248 

psoriasis, 232 
Syphiloma, 252 
Syrupus trifolii comp., 280 

Taches syphilitiques, 262 
Telangiectasis, 194 
Tertiary syphilitic eruptions, 246 
Tinea circinata, 201 

favosa, 200 

sycosis, 202 

tonsurans, 202 

trichophytina, 201 

versicolor, 203 
treatment of, 204 
Treatment of the syphilides, 268 



Index. 



303 



Tubercular syphilide, 248 
diagnosis of, 250 
prognosis of, 251 

Ulcerating syphilide, 257 

diagnosis of, 259 

prognosis of, 262 
Ungiarola, 268 
Uridrosis, 10 
Urinous sweat, 10 
Urticaria, 70 

causation of, 71 

diagnosis of, 73 

pathology of, 74 

treatment of, 76 

Van Swieten's liquor, 271 
Variolaform syphilide, 243 



Vascular new formations, 192 
Virchow on histology of syphilitic 

infiltrations, 253 
Vitiligo, 161 

Warts, 134 

electrolysis in, 136 
Wen, 21 

Xanthoma, 176 
Xeroderma of Hebra, 140 
simplex, 142 

Zeissl on treatment of moist pap- 
ules, 286 
Zittmann's decoction, 281 
Zoster, 92 



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laborator American Naturalist, Alienist, and Neurologist, Journal of 
Neurology and Psychiatry, Journal of Nervous and Mental Diseases; 
Author of " Comparative Physiology and Psychology," etc. 

For more than twenty years this subject has occasioned bitter con- 
tention in law courts between physicians as well as attorneys, and in that 
time no work has appeared that reviewed the entire field judicially 
until Dr. Clevengers book was written. It is the outcome of five 
years' special study and experience in legal circles, clinics, hospital 
and private practice, in addition to twenty years' labor as a scientific 
student, writer, and teacher. Every Physician and Laioyer should own 
this work. In one handsome Royal Octavo volume of nearly 400 pages, 
with 30 Wood-Engravings. 

Price, in United States and Canada, post-paid, $2.50, net; 
Great Britain, 14s. ; France, 15 fr. 



DAVIS— Consumption : How to Prevent it, and How to 
Live with it. Its Nature, Causes, Prevention, and 
the Mode of Life, Climate, Exercise, Food and 
Clothing Necessary for its Cure. 

By N. S. Davis, Jr., A.M., M.D., Professor of Principles and 
Practice of Medicine in Chicago Medical College ; Physician to Mercy 
Hospital; Member of the American Medical Association, Illinois 
State Medical Society, etc., etc. 12mo. In Press. 



Catalogue of Medical Publications. 



DAVIS — Diseases of the Heart, Lungs, and Kidneys. 

By N. S. Davis, Jr., A.M.,M.D., Professor of Principles and 
Practice of Medicine in the Chicago Medical College, Chicago, 111., 
etc. In one neat 12mo volume. No. in the Physicians' and Students' 
Beady-Reference Series. In Preparation. 



DEMARQUAY — Essay on Medical Pneumatology and 
Aerotherapy. A Practical Investigation of the Clini- 
cal and Therapeutic Value of the Gases in Medical 
and Surgical Practice, with Especial Reference to 
the Value and Availability of Oxygen, Nitrogen, 
Hydrogen, and Nitrogen Monoxide. 

By J. N. Demarquay, Surgeon to the Municipal Hospital, Paris, 
and of the Council of State ; Member of the Imperial Society of Sur- 
gery; Correspondent of the Academies of Belgium, Turin, Munich, 
etc. ; Officer of the Legion of Honor ; Chevalier of the Orders of Isa- 
bella-the-Catholic and of the Conception, of Portugal, etc. Translated, 
with notes, additions, and omissions, by Samuel S. Wallian, A.M., 
M.D., Member of the American Medical Association ; Ex-President of 
the Medical Association of Northern New York ; Member of the New 
York County Medical Society, etc. In one handsome Octavo volume 
of 316 pages, printed on fine paper, in the Best Style of the Printer's 
Art, and Illustrated with 21 Wood-Cuts. 

Price, in United States and Canada, post-paid, Cloth, $3.00, 
net; Half-Russia, $3.00, net. Great Britain, Cloth, lis. 
6d. ; Half-Russia, 17s. France, Cloth, 13 fr. 40 ; Half- 
Russia, 18 fr. 60. 



EDINGER — Twelve Lectures on the Structure of the 
Central Nervous System. For Physicians and 
Students. 

By Dr. Ludwig Edinger, Frankfort-on-the-Main. Second Re- 
vised Edition. With 133 illustrations. Translated by Willis Hall 
Vittum, M.D., St. Paul, Minn. Edited by C. Eugene Riggs, A.M., 
M.D., Professor of Mental and Nervous Diseases, University of Minne- 
sota ; Member of the American Neurological Association. The illus- 
trations are exactly the same as those used in the latest German 
edition (with the German names translated into English), and are 
very satisfactory to the Physician and Student using the book. The 
work is complete in one Royal Octavo volume of about 250 pages, 
bound in Extra Cloth. 

Price, in United States and Canada, post-paid, $1.75, net ; 
Great Britain, 10s. ; France, 13 fr. 20* 



F. A. Davis, Philadelphia, Pa. 



EISENBERG — Bacteriological Diagnosis. Tabular Aids 
for Use in Practical Work. 

By James Eisexberg, Ph.D., M.D., Vienna. Translated and 
augmented, with the permission of the author, from the latest German 
Edition, by Norval H. Pierce, M.D., Surgeon to the Out-Door 
Department of Michael Reese Hospital ; Assistant to Surgical Clinic, 
College of Physicians and Surgeons, Chicago, 111. In one Octavo 
volume, handsomely bound in Cloth. In Press. 

GOODELL — Lessons in Gynaecology. 

By William Goodell, A.M., M.D., etc., Professor of Clinical 
Gynaecology in the University of Pennsylvania. With 112 illustra- 
tions. Third Edition, thoroughly revised and greatly enlarged. One 
volume, large Octavo, 578 pages. 

Price, in United States and Canada, Cloth, S5.00 ; Full 
Sheep, S6.00. Discount, 20 per cent., making- it, net, 
Cloth, §4.00; Sheep, §4.80. Postage, 27 cents extra. 
Great Britain, Cloth, 22s. 6d. ; Sheep, 28s. France, 30 
fir. 80. 

This exceedingly valuable work, from one of the most eminent 
specialists and teachers in gynaecology in the United States, is now 
offered to the profession in a much more complete condition than 
either of the previous editions. It embraces all the more important 
diseases and the principal operations in the field of gynaecology, and 
brings to bear upon them all the extensive practical experience and 
wide reading of the author. It is an indispensable guide to every 
practitioner who has to do with the diseases peculiar to women. 

GUERNSEY— Plain Talks on Avoided Subjects. 

By Henry N. Guernsey, M.D., formerly Professor of Materia 
Medica and Institutes in the Hahnemann Medical College of Philadel- 
phia ; Author of Guernsey's "Obstetrics," including the Disorders 
Peculiar to Women and Young- Children ; Lectures on Materia Medica, 
etc. The following Table of Contents shows the scope of the book : — 

Contents. — Chapter I. Introductory. II. The Infant. III. 
Childhood. IV. Adolescence of the Male. V. Adolescence of the 
Female. VI. Marriage: The Husband. VII. The Wife. VIII. Hus- 
band and Wife. IX. To the Unfortunate. X. Origin of the Sex. In 
one neat 16mo volume, bound in Extra Cloth. 

Price, in United States and Canada, post-paid, SI. 00 ; Great 
Britain, 6s. 6d. ; France, 6 fr. 20. 

HARE — Epilepsy : its Pathology and Treatment. Being 
an Essay to which was Awarded a Prize of Four 
Thousand Francs by the Academie Royal de Mede- 
cine de Belgiaue, December 31, 1889. 

By Ho bart Amort Hare, M.D. (University of Pennsylva- 
nia), B.Sc, Clinical Professor of the Diseases of Children, and 
Demonstrator of Therapeutics in the University of Pennsylvania; 



Catalogue of Medical Publications. 



Laureate of the Royal Academy of Medicine in Belgium, of the 
Medical Society of London, etc. 12mo. 228 pages. Neatly bound in 
Dark-blue Cloth. No. 7 in the Physicians' and Students' Ready -Refer- 
ence Series. 

Price, in United States and Canada, post-paid, $1.25, net; 
Great Britain, 6s. 6d. ; France, 7 fr. 75. 

"This little work is an admirably con- I wish to have the facts concerning epi- 
densed statement of the clearest authen- lepsy in the most available form." — 



ticated facts on this subject known. The i Quarterly Journal of Inebriety. 
author is evidently a master in the art 
of clear, condensed statements of what 
is known, and he could do a great ser- 
vice to science by 'boiling down' some 
of the thousand-page volumes that are 



"It is representative of the most ad- 
vanced views of the profession, and the 
subject is pruned of the vast amount of 
superstition and nonsense that generally 



coming from the press. This work is obtains in connection with epilepsy." — 
of great value to all physicians who | Medical Age. 

HARE — Fever : its Pathology and Treatment. Being 

the Boylston Prize Essay of Harvard Univer- 
sity for 1890 ; containing Directions and the Latest 
Information Concerning the Use of the So- Called 
Antipyretics in Fever and Pain. 

By Hobart Amort Hare, M.D. (University of Pennsyl- 
vania), B.Sc., Clinical Professor of the Diseases of Children and 
Demonstrator of Therapeutics in the University of Pennsylvania ; 
Physician to St. Agnes' Hospital and to the Children's Dispensary of 
the Children's Hospital ; Laureate of the Royal Academy of Medicine 
in Belgium, of the Medical Society of London; Member of the Asso- 
ciation of American Physicians, etc. Illustrated with more than 25 
new plates of tracings of various fever cases, showing beautifully and 
accurately the action of the antipyretics. The work also contains 
35 carefully-prepared statistical tables of 249 cases, showing the un- 
toward effects of the antipyretics. 12mo. Neatly bound in Dark- 
Blue Cloth. No. 10 in the Physicians' and Students' Ready-Reference 
Series. 

Price, in United States and Canada, post-paid, §81.25, net ; 
Great Britain, 6s. 6d. ; France, 7 Ir. 75. 

JAMES — American Resorts, with Notes upon Their 
Climate. 

By Bushrod W. James, A.M., M.D., Member of the American 
Association for the Advancement of Science, the American Public 
Health Association, the Pennsylvania Historical Society, the Franklin 
Institute, and the Academy of Natural Sciences, Philadelphia; the 
Society of Alaskan Natural History and Ethnology, Sitka, Alaska, 
etc. With a translation from the German, by Mr. S. Kauffmann, 
of those chapters of "Die Klimate der Erde," written by Dr. A. Woe- 
ikof, of St. Petersburg, Russia, that relate to North and South Ameri- 
ca, and the islands and oceans contiguous thereto. In one Octavo 
volume, handsomely bound in Cloth. Nearly 300 pages. 

Price, in United States and Canada, post-paid, S2.00, net; 
Great Britain, lis. 6. ; France, 13 £r. 40. 



F. A. Davis, Philadelphia, Pa. 



KEATING— Record-Book of Medical Examinations for 
Life-Insurance. 

Designed by Johx M. Keating, M.D. This record-book is small, 
neat, and complete, and embraces all the principal points that are 
required by the different companies. It is made in two sizes, viz. : 
No. 1, covering one hundred (100) examinations, and No. 2. covering 
two hundred (200) examinations. The size of the book is 7 x 3% 
inches, and can be conveniently carried in the pocket. 

Prices, post-paid : No. 1, for 100 Examinations, bonnd in 
Cloth, United States and Canada, 50 Cents, net ; (ireat 
Britain, 3s. 6d. ; France, 3 fr. 60. Xo. 2, for 200 Ex- 
aminations, hound in Full Leather, with Side-Flap, 
United States and Canada, .^1.00, net; Great Britain, 
6s. 6d.; France, 6 fr 20. 

m 

KEATING AND EDWARDS -Diseases of the Heart 
and Circulation in Infancy and Adolescence. With 

an Appendix entitled u Clinical Studies on the 
Pulse in Childhood.'' 1 

By Johx M. Keatixo. M.D., Obstetrician to the Philadelphia 
Hospital and Lecturer on Diseases of Women and Children ; Surgeon 
to the Maternity Hospital ; Physician to St. Joseph's Hospital; Fellow 
of the College of Physicians of Philadelphia, etc. ; and William A. 
Edwards, M.D., formerly Instructor in Clinical Medicine and Physi- 
cian to the Medical Dispensary in the University of Pennsylvania ; 
Physician to St. Joseph's Hospital ; Fellow of the College of Physi- 
cians ; formerly Assistant Pathologist to the Philadelphia Hospital, etc. 
Illustrated by Photographs and Wood-Engravings. About 225 pages. 
8vo. Bound in Cloth. 

Price, in United States and Canada, post-paid, SI. 50, net; 
Great Britain, 8s. 6d. ; France, 9 fr. 35. 

KELLER— Perpetual Clinical Index to Materia Medica, 
Chemistry, and Pharmacy Charts. 

By A. H. Keller. Ph. G., M.D., consisting of (1) the " Perpetual 
Clinical Index," an oblong volume, 9x6 inches, neatly bound in Extra 
Cloth ; (2) a Chart of " Materia Medica," 32 x 44 inches, mounted on 
muslin, with rollers; (3) a Chart of ''Chemistry and Pharmacy," 
32 x 44 inches, mounted on muslin, with rollers. 

Price for the Complete Work, United States, S5.00 net ; Canada 
(duty paid) S5.50, net ; Great Britain, 28s. ; France, 30 fr. 30. 

LIEBIG and ROHE— Practical Electricity in Medicine 
and Surgery. 

By G. A. Liebig. Jr., Ph.D., Assistant in Electricity, Johns Hop- 
kins University: Lecturer on Medical Electricity, College of Phy- 
sicians and Surgeons, Baltimore ; Member of the American Institute 



Catalogue of Medical Publications. 



of Electrical Engineers, etc. ; and George H. Rohe, M.D., Professor 
of Obstetrics and Hygiene, College of Physicians and Surgeons, Balti- 
more ; Visiting Physician to Bay View and City Hospitals ; Director 
of the Maryland Maternite ; Associate Editor "Annual of the Uni- 
versal Medical Sciences," etc. Profusely Illustrated by Wood-Engrav- 
ings and Original Diagrams, and published in one handsome Royal 
Octavo volume of 383 pages, bound in Extra Cloth. 

Price, in United States and Canada, post-paid, §§2.00, net; 
Great Britain, lis. 6d. ; France, 12 fr. 40. 

The constantly increasing demand for this work attests its thorough 
reliability and its popularity with the profession, and points to the 
fact that it is already the standard work on this very important sub- 
ject. The part on Physical Electricity, written by Dr. Liebig, one of 
the recognized authorities on the science in the United States, treats 
fully such topics of interest as Storage Batteries, Dynamos, the Elec- 
tric Light, and the Principles and Practice of Electrical Measurement 
in their Relations to Medical Practice. Professor Rohe, who writes on 
Electro-Therapeutics, discusses at length the recent developments of 
Electricity in the treatment of stricture, enlarged prostate, uterine 
fibroids, pelvic cellulitis, and other diseases of the male and female 
gen i to-urinary organs, etc., etc. 



MANTON— Childbed ; its Management; Diseases and 
their Treatment. 

By Walter P. Manton, M.D., Visiting Physician to the De- 
troit Woman's Hospital; Consulting Gynaecologist to the Eastern 
Michigan Asylum; President of the Detroit Gynaecological Society; 
Fellow of the American Society of Obstetricians and Gynaecologists, 
and of the British Gynaecological Society ; Member of Michigan State 
Medical Society, etc. In one neat 12mo volume. N~o. in the Phy- 
sicians' and Students' Ready-Reference Series. In Preparation. 



MASSEY — Electricity in the Diseases of Women. With 

Special Reference to the Application of Strong 
Currents. 

By G. Betton Massey, M.D., Physician to the Gynaecological 
Department of the Howard Hospital; Late Electro-Therapeutist to the 
Philadelphia Orthopaedic Hospital and Infirmary for Nervous Diseases; 
Member of the American Neurological Association, of the Philadel- 
phia Neurological Society, of the Franklin Institute, etc. Second 
Edition. Revised and enlarged. With New and Original Wood- 
Engravings. Handsomely bound in Dark-Blue Cloth. 240 pages. 
12mo. No. 5 in the Physicians' and Students' Ready-Reference Series. 

Price, in United States and Canada, post-paid, §§1.50, net; 
Great Britain, 8s. 6d. ; France, 9 fr. 35. 



F. A. Davis, Philadelphia, Pa. 



"A new edition of this practical 
manual attests the utility of its exist- 
ence and the recognition of its merit. 
The directions are simple, easy to fol- 
low and to put into practice, the ground 
is well covered, and nothing is assumed, 
the entire book being the record of ex- 
perience." — Journal of Nervous and 
Mental Diseases. 

"It is only a few months since we 
noticed the first edition of this little 
book ; and it is only necessary to add 
now that we consider it the best treatise 



on this subject we have seen, and that 
the improvements introduced into this 
edition make it more valuable still." — 
Boston Medical and Surgical fourn. 
"The style is clear, but condensed. 
Useless details are omitted, the reports 
of cases being pruned of all irrelevant 
material. The book is an exceedingly 
valuable one, and represents an amount 
of study and experience which is only 
appreciated after a careful reading." — 
Medical Record. 



MEARS— Practical Surgery. 



By J. Ewing Mears, M.D., Lecturer on Practical Surgery and 
Demonstrator of Surgery in Jefferson Medical College ; Professor of 
Anatomy and Clinical Surgery in the Pennsylvania College of Dental 
Surgery, etc. Third Edition. Revised and Enlarged. In Prep- 
aration. 



Medical Bulletin Visiting List, or Physicians' Call 
Record. Arranged upon an Original and Con- 
venient Monthly and Weekly Plan for the Daily 
Recording of Professional Visits. 

This is, beyond question, the best and most convenient time- and 
labor- saving physicians' pocket record-book ever published. Phy- 
sicians of many years 7 standing and with large practices pronounce 
this the best list they have ever seen. It is handsomely bound in fine, 
strong leather, with flap, including a pocket for loose memoranda, etc., 
and is furnished with a Dixon lead-pencil of excellent quality and 
finish. It is compact and convenient for carrying in the pocket. Size, 
4 x 6X inches. In three styles. Send for Descriptive Circular. 

Net Price, post-paid; No. 1, Regular Size, for 70 patients 
daily each month for one year, United States and Canada, 
$1.25; France, 7 fr. 75. No. 2, Large Size, for 105 
patients daily each month for one year, United States and 
Canada, $1.50; France, 9 fr. 35. No. 3, in which "The 
Blanks for Recording Visits in" are in six (6) removable 
sections, United States and Canada, $1.75 ; France, 13 
fr. 30. 

Special Edition for Great Britain only, 4s. 6d. 



MICHENER — Hand-Book of Eclampsia; or, Notes and 
Gases of Puerperal Convulsions. 

By E. Michener, M.D. ; J. H. Stubbs, M.D. ; R. B. Ewing, 
M.D.; B. Thompson, M.D.; S. Stebbins, M.D. 16mo. Cloth. 

Price, 60 cents, net ; Great Britain, 4s. 6d. ; France, 4 fr. SO. 



10 Catalogue of Medical Publications. 

NISSEN — A IVSanua! of Instruction fop Giving Swedish 
Movement and Massage Treatment. 

By Prof. Hartvig Nissen, Director of the Swedish Health In- 
stitute, Washington, D.C. ; late Instructor in Physical Culture and 
Gymnastics at the Johns Hopkins University, Baltimore, Md, ; Author 
of "Health by Exercise without Apparatus/' Illustrated with 29 
Original Wood-Engravings. In one 12mo volume of 128 pages. Neatly 
bound in Cloth. 

Price, in United States and Canada, post-paid, §1.00, net ; 
Great Britain, 6s. ; France, 6 fr. 20. 

Physicians' All-Requisite Time- and Labor- Saving 
Account- Book. Being a Ledger and Account-Book 
for Physicians 1 Use, Meeting all the Requirements 
of the Law and Courts. 

Designed by William A. Seibert, M.D., of Easton, Pa. There 
is no exaggeration in stating that this Account-Book and Ledger re- 
duces the labor of keeping your accounts more than one-half, and at 
the same time secures the greatest degree of accuracy. 

To all physicians desiring a quick, accurate, and comprehensive 
method of keeping their accounts, we can safely say that no book as 
suitable as this one has ever been devised. 

Prices, Shipping Expenses Prepaid : No. 1, 300 Pages, for 
900 Accounts per Year, Size 10 x 12, Bound in %-Russia, 
liaised Back-Bands, Cloth Sides, in United States, $5.00 ; 
Canada (duty paid), 85.50, net; Great Britain, 28s.; 
France, 30 fr. 30. No. 2, 600 Pages, for 1800 Accounts 
per Year, Size 10 x 12, Bound in %-Russia, Raised Back- 
Bands, Cloth Sides, in United States, $8.00 ; Canada (duty 
paid), 88.80; net ; Great Britain, 42s. ; France, 49 fr. 40. 

A circular showing the plan of the book will be sent free to any 
address on application. 

Physicians' Interpreter: In Four Languages (English, 
French, German, and Italian). 

Specially arranged for diagnosis by M. von V. The object of this 
little work is to meet a need often keenly felt by the busy physician, 
namely, the need of some quick and reliable method of communicat- 
ing intelligibly with patients of those nationalities and languages un- 
familiar to the practitioner. The plan of the book is a systematic 
arrangement of questions upon the various branches of Practical 
Medicine, and each question is so worded that the only answer re- 
quired of the patient is merely Yes or No. The questions are all 
numbered, and a complete Index renders them always available for 
quick reference. The book is written by one who is well versed in 
English, French, German, and Italian, being an excellent teacher in 
those languages, and who has also had considerable hospital experience. 
Bound in full Russia Leather, for carrying in the pocket. Size, 5 x 2% 
inches. 206 pages. 

Price, in United States and Canada, post-paid, $1,00, net; 
Great Britain, 6s. ; France, 6 fr. 20. 



F A. Davis, Philadelphia, Pa. 11 



PRICE AND EAGLETON— Three Charts of the Nervo- 
Vascular System. Part I. — The Nerves. Part II. 
— The Arteries. Part III. — The Veins. 

A New edition. Revised and Perfected. Arranged by W. Henry 
Price, M.D., and S. Potts Eagletox, M.D. Endorsed by leading 

Anatomists. "The Xervo- Vascular System of Charts" far excels 
every other system in their completeness, compactness, and accuracy. 
Clearly and beautifully printed upon extra-durable paper. Each chart 
measures 19 x 24 inches. 

Price, in the United States and Canada, post-paid, 50 cents, net, 
Complete ; Great Britain, 3s. 6d. ; France, 3 fr. 60. 

PURDY— Diabetes: its Cause, Symptoms, and Treat- 
ment. 

By Chas. W. Purdy, M.D. (Queen's University), Honorary 
Fellow of the Royal College of Physicians and Surgeons of Kingston ; 
Member of the College of Physicians and Surgeons of Ontario : Author 
of " Bright's Disease and Allied Affections of the Kidneys : " Member 
of the Association of American Physicians ; Member of the American 
Medical Association ; Member of the Chicago Academy of Sciences, 
etc., etc. With Clinical Illustrations. In one neat 12mo volume. 
Handsomely bound in Dark-Blue Cloth. iVo. 8 in the Physicians' and 
Students 1 Beady-Reference series. 

Price, United States and Canada, SI. 25, net ; Great Britain, 
6s. 6d. ; France, 7 fr. 75 ; post-paid. 

REMONDINO— Circumcision: its History, Modes of 
Operation, etc. From the Earliest Times to the 
Present ; with a History of Eunuchism, Hermaphro- 
dism, etc., as Observed Among All Paces and Nations ; 
also a Description of the Different Operative Methods 
of Modem Surgery Practiced upon the Prepuce. 

By P. C. Remoxdixo, M.D. (Jefferson) ; Member of the Ameri- 
can Medical Association; Member of the American Public Health 
Association; Member of the State Medical Society of California, and 
of the Southern California Medical Society. Ix Press. Nearly 
Ready. No. 11 in the Physicians' and Students' Ready-Reference Series. 

ROHE — Text-Book of Hygiene. A Comprehensive 
Treatise on the Principles and Practice of Pre- 
ventive Medicine from an American Stand-point. 

By George H. Rohe, M.D., Professor of Obstetrics and Hygiene 
in the College of Physicians and Surgeons, Baltimore ; Member of the 
American Public Health Association, etc. 



12 Catalogue of Medical Publications. 

Second Edition, thoroughly revised and largely rewritten, with 
many illustrations and valuable tables. In one handsome Royal 
Octavo volume of over 400 pages, bound in Extra Cloth. 

Price, United States, post-paid, $2.50, net ; Canada (duty paid) 
852.75, net ; Great Britain, 14s. ; France, 16 fr. 20. 

Every Sanitarian should have Roh6's " Text-Book of Hygiene " as 
a work of reference. Of this new (second) edition, one of the best 
qualified judges, namely, Albert L. Gihon, M.D., Medical Director of 
TJ. S. Navy, in charge of U. S. Naval Hospital, Brooklyn, N. Y., and 
ex-President of the American Public Health Association, writes : "It 
is the most admirable, concise remme of the facts of Hygiene with 
which I am acquainted. Professor Rohe's attractive style makes the 
book so readable that no better presentation of the important place of 
Preventive Medicine, among their studies, can be desired for the 
younger members, especially, of our profession." 



SAJOUS— Hay Fever and its Successful Treatment by 
Superficial Organic Alteration of the Nasal Mucous 
Membrane. 

By Charles E. Sajous, M.D., formerly Lecturer on Bhinology 
and Laryngology in Jefferson Medical College ; Vice-President of the 
American Laryngological Association ; Officer of the Academy of 
France and of Public Instruction of Venezuela ; Corresponding Member 
of the Royal Society of Belgium, of the Medical Society of Warsaw 
(Poland), and of the Society of Efygiene of France ; Member of the 
American Philosophical Society, etc., etc. With 13 Engravings on 
Wood. 12mo. Bound in Cloth. Beveled edges. 

Price, in United States and Canada, $1.00, net; Great 
Britain, 6s. ; France, 6 fr. 20. 



SANNE— Diphtheria, Croup: Tracheotomy and Intuba- 
tion. 

From the French of A. Sanne. Translated and enlarged by 
Henry Z. Gill, M.D., LL.D. Diphtheria having become such a 
prevalent, wide-spread, and fatal disease, no general practitioner can 
afford to be without this work. It will aid in preventive measures, 
stimulate promptness in the application of and efficiency in treatment, 
and moderate the extravagant views which have been entertained re- 
garding certain specifics in the disease diphtheria. 

A full Index accompanies the enlarged volume, also a list of 
authors, making, altogether, a very handsome Illustrated volume 
of over 680 pages. 

Price, United States, post-paid, Cloth, $4.00 , Leather, $5.00. 
Canada (duty paid), Cloth, $4.40 ; Leather, $5.50, net. 
Great Britain, Cloth, 22s. 6d. ; Leather, 28s. France, 
Cloth, 24 fr. 60 ; Leather, 30 fr. 30. 



F. A. Dan's, Philadelphia, Pa. 13 

SENN— Principles of Surgery. 

By N. Senx, M.D., Ph.D., Professor of Principles of Surgery and 
Surgical Pathology in Rush Medical College, Chicago. 111.; Professor 
of Surgery in the Chicago Polyclinic; Attending Surgeon to the Mil- 
waukee Hospital ; Consulting Surgeon to the Milwaukee County Hos- 
pital and to the Milwaukee County Insane Asylum. 

In one handsome Royal Octavo volume, with 109 fine Wood-En- 
gravings and 624 pages. 

Price, in United States, Cloth, §4.50 ; Sheep or Half-Russia, 
So. 50, net. Canada (duty paid), Cloth, §§5.00 ; Sheep or 
Half-Russia, S6.10, net; Great Britain, Cloth, 24s. 6d. ; 
Sheep or Half-Russia, 30s. France, Cloth, 27 fir. 20; 
Sheep or Half-Russia, 33 fr. 10. 

This work, by one of America's greatest surgeons, is thoroughly 
complete ; its clearness and brevity of statement are among its con- 
spicuous merits. The author's long, able, and conscientious researches 
in every direction in this important field are a guarantee of unusual 
trustworthiness, that every branch of the subject is treated authorita- 
tively and in such a manner as to bring the greatest gain in knowledge 
to the Practitioner and Student. Physicians and Surgeons alike should 
not deprive themselves of this very important work. 

A critical examination of the Wood- Engravings (109 in number) wiU 
reveal the fact that they are thoroughly accurate and produced by the best 
artistic ability. 



Stephen Smith, M.D., Professor of 
Clinical Surgery in Medical Department 
of University of the City of New York, 
writes: "I have examined the work 
with great satisfaction, and regard it as 
a most valuable addition to American 
Surgical literature. There, has long 
been great need of a work on the prin- 
ciples of Surgery which would fully 
illustrate the present advanced state of 
knowledge of the various subjects em- 
braced in this volume. The work seems 
to me to meet this want admirably." 

u The achievements of Modern Sur- 
gery are akin to the marvelous, and Dr 
Senn has set forth the principles of the 
science with a completeness that seems 



to leave nothing further to be said until 
new discoveries are made. The work 
is systematic and compact, without a 
fact omitted or a sentence too much, 
and it not only makes instructive but 
fascinating reading. A conspicuous 
merit of Senn's work is his method, his 
persistent and tireless search through 
original investigations for additions to 
knowledge, and the practical character 
of his discoveries. This combination 
of the discoverer and the practical man 
gives a special value to all his work, 
and is one of the secrets of his fame. 
No physician, in any line of practice, 
can afford to be without Senn's ' Prin- 
ciples of Surgery.' " — The Review of 
Insanity and Nervous Diseases. 



SHOEMAKER— Heredity, Health, and Personal Beauty. 

Tartu ding the Selection of the Best Cosmetics for 
the Skin, Hair, Nails, and All Parts Relating to the 
Body. 

By John V. Shoemaker, A.M., M.D., Professor of Materia 

Medica. Pharmacology, Therapeutics, and Clinical Medicine, and 
Clinical Professor of Diseases of the Skin in the Medico-Chirurgical 
College of Philadelphia; Physician to the Medico-Chirurgical Hos- 
pital, etc.. etc. This is just the book to place on the waiting-room table 
of every 'physician, and a work that will prove useful in the hands of your 
patients. 



14 Catalogue of Medical Publications. 

The health of the skin and hair, and how to promote them, are 
discussed ; the treatment of the nails ; the subjects of ventilation, 
food, clothing, warmth, bathing; the circulation of the blood, diges- 
tion, ventilation; in fact, all that in daily life conduces to the well- 
being of the body and refinement is duly enlarged upon. To these 
stores of popular information is added a list of the best medicated 
soaps and toilet soaps, and a whole chapter of the work is devoted to 
household remedies. 

The work is largely suggestive, and gives wise and timely advice 
as to when a physician should be consulted. 

Complete in one handsome Royal Octavo volume of 425 pages, 
beautifully and clearly printed, and bound in Extra Cloth, Beveled 
Edges, with side and back gilt stamps and Half-Morocco Gilt Top. 

Price, in United States, post-paid, Cloth, S3. 50 ; Half- 
Morocco, S3. 50 net. Canada (duty paid), Cloth, S3. 75; 
Half-Morocco, $3.90, net. Great Britain, Cloth, 14s.; 
Half-Morocco, 19s. 6d. France, Cloth, 15 fr. ; Half- 
Morocco, 22 fr. 

SHOEMAKER— Materia Medica and Therapeutics. With 

Especial Reference to the Clinical Application of 
Drugs. 

Being the second and last volume of a treatise on Materia Medica, 
Pharmacology, and Therapeutics, and an independent volume upon 
drugs. 

By John V. Shoemaker, A.M., M.D., Professor of Materia 
Medica, Pharmacology, Therapeutics, and Clinical Medicine, and 
Clinical Professor of Diseases of the Skin in the Medico Chirurgical 
College of Philadelphia ; Physician to the Medico-Chirurgical Hos- 
pital, etc. ,etc. 

This is the long-looked-for second volume of Shoemaker's Materia 
Medica, Pharmacology, and Therapeutics. It is wholly taken up with 
the consideration of drugs, each remedy being studied from three 
points of view, viz. : the Preparations, or Materia Medica; the 
Physiology and Toxicolog} r , or Pharmacology ; and, lastly , its Therapy. 
Dr. Shoemaker has finalty brought the work to completion, and now 
this second volume is ready for delivery. It is thoroughly abreast of 
the progress of Therapeutic Science, and is really an indispensable 
book to every student and practitioner of medicine. Royal Octavo, 
about 675 pages. Thoroughly and carefully indexed. 

Price, in United States, post-paid, Cloth, $3.50; Sheep, $4.50, 
net. Canada (duty paid), Cloth, $4.00; Sheep, $5.00, 
net. Great Britain, Cloth, 20s. ; Sheep, 26s. France, 
Cloth, 22 fr. 40 ; Sheep, 28 fr. 60. 

The first volume of this work is devoted to Pharmacy, General 
Pharmacology, and Therapeutics, and remedial agents not properly 
classed with drugs. Koyal Octavo, 353 pages. Price of Volume I, 
post-paid, in United States, Cloth, $2.50, 'net; Sheep, $3.25, net. 
Canada, duty paid, Cloth, $2.75, net ; Sheep, $3.60, net. Great Britain, 
Cloth, 14s., Sheep, 18s. France, Cloth, 16 fr. 20; Sheep, 20 fr. 20. 
The volumes are sold separately. 



F. A. Davis, Philadelphia, Pa. 



15 



SHOEMAKER— Ointments and Oleates, Especially in 
Diseases of the Skin. 

By John V. Sfoemaker, A.M., M.D., Professor of Materia 
Medica, Pharmacology, Therapeutics, and Clinical Medicine, and 
Clinical Professor of Diseases of the Skin in the Medico-Chirurgical 
College of Philadelphia, etc., etc. Second Edition, revised and en- 
larged. 298 pages. 12mo. Neatly bound in Dark-Blue Cloth. No. 6 
in the Pliyzicians' and Students' Beady -Reference Series. 

Price, in United States and Canada, post-paid, SS1.50, net ; 
Great Britain, 8s. 6d. ; France, 9 fr. 35. 

The author concisely concludes his preface as follows: " The 
reader may thus obtain a conspectus of the whole subject of inunction 
as it exists to-day in the civilized world. In all cases the mode of 
preparation is given, and the therapeutical application described 
seriatim, in so far as may be done without needless repetition." 

It is invaluable as a ready reference 
when ointments or oleates are to be 
used, and is serviceable to both druggist 
and physician. — Canada Medical Rec- 
ord. 

To the physician who feels uncertain 
as to the best form in which to prescribe 



medicines by way of the skin the book 
will prove valuable, owing to the many 
prescriptions and formulae which dot 
its pages, while the copious index at the 
back materially aids in making the book 
a useful one. — Medical News. 



SMITH — The Physiology of the Domestic Animals. A 

Text-Book for Veterinary and Medical Students 
and Practitioners. 

By Robert Meade Smith, A.M., M.D., Professor of Comparative 
Physiology in University of Pennsylvania ; Fellow of the College of 
Physicians and Academy of the Natural Sciences, Philadelphia ; of the 
American Physiological Society ; of the American Society of Natural- 
ists ; Associe Etranger de la Societe Francaised'Hygiene, etc. In one 
handsome Royal Octavo volume of over 950 pages. Profusely illus- 
trated with more than 400 fine Wood-Engravings and many Colored 
Plates. 

Price, in United States, Cloth, So. 00; Sheep, S8.00, net. 
Canada (duty paid), Cloth, ^5.50; Sheep, S6.60, net. 
Great Britain, Cloth, 28s.; Sheep, 32s. France, Cloth, 
30 fr. 30 ; Sheep, 36 fr. 20. 

This new and important work is the most thoroughly complete in 
the English language on the subject. In it the physiology of the 
domestic animals is treated in a most comprehensive manner, especial 
prominence being given to the subject of foods and fodders, and the 
character of the diet for the herbivora under different conditions, with 
a full consideration of their digestive peculiarities. Without being 
overburdened with details, it forms a complete text-book of physiology, 
adapted to the use of students and practitioners of both veterinary and 
human medicine. This work has already been adopted as the Text- 
Book on Physiology in the Veterinary Colleges of the United States, 
Great Britain, and Canada. 



16 Catalogue of Medical Publications. 

SOZINSKEY — Medical Symbolism. Historical Studies 
in the Arts of Healing and Hygiene. 

By Thomas S. Sozinskey, M.D., Ph.D., Author of " The 
Culture of Beauty," "The Care and Culture of Children," etc. 
12mo. Nearly 200 pages. Neatly bound in Dark-Blue Cloth. Appro- 
priately illustrated with upward of thirty (30) new Wood-Engravings. 
Ao. 9 in the Physicians' and Students 7 Ready-Reference Series. 

Price, in United States and Canada, post-paid, $1.00, net; 
Great Britain, 6s. ; France, 6 fr. 30. 

STEWART— Obstetric Synopsis. 

By John S. Stew^art, M.D., Demonstrator of Obstetrics and 
Chief Assistant in the Gynaecological Clinic of the Medico- Chirurgical 
College of Philadelphia; with an introductory note by William S. 
Stewart, A.M., M.D., Professor of Obstetrics and Gynaecology in the 
Medico-Chirurgical College of Philadelphia. 42 Illustrations. 202 
pages. 12mo. Handsomely bound in Dark-Blue Cloth. A r o. 1 in the 
Physicians' and Students' Ready-Reference Series. 

Price, in United States and Canada, post-paid, &1.00 net ; 
Great Britain, 6s. 6d. ; France, 6 fr. 20. 

ULTZMANN — The Neuroses of the Genito-Urinary Sys- 
tem in the Male. With Sterility and Impotence. 

By Dr. R. Ultzmann, Professor of Genito-Urinary Diseases in 
the University of Vienna. Translated, with the author's permission, 
by Gardner W. Allen, M.D., Surgeon in the Genito-Urinary De- 
partment, Boston Dispensary. Illustrated. 12mo. Handsomely bound 
in Dark-Blue Cloth. JS r o. 4 in ^ ie Physicians' and Students' Ready- 
Reference Series. 

Price, in United States and Canada, post-paid, $1.00, net; 
Great Britain, 6s. ; France, 6 fr. 20. 

Synopsis of Contents. — First Part — I. Chemical Changes in 
the Urine in Cases of Neuroses. II. Neuroses of the Urinary and of 
the Sexual Organs, classified as: (1) Sensory Neuroses; (2) Motor Neu- 
roses; (3) Secretory Neuroses. Second Part — Sterility and Impotence. 
The treatment in all cases is described clearly and minutely, 

WHEELER — Abstracts of Pharmacology. 

By H. A. Wheeler, M.D. (Begistered Pharmacist, No. 3468, 
Iowa). Prepared for the use of Physicians and Pharmacists, and 
especially for the use of Students of Medicine and Pharmacy, who 
are preparing for Examination in Colleges and before State Boards of 
Examiners. 

This book does not contain questions and answers, but solid pages 
of abstract information. It will be an almost indispensable companion 
to the practicing Pharmacist and a very useful reference-book to the 



F. A. Davis, Philadelphia, Pa. 17 

Physician. It contains a brief but thorough explanation of all terms 
and processes used in practical pharmacy, an abstract of all that is 
essential to be known of each officinal drug, its preparations and 
therapeutic action, with doses; in Chemistry and Botany, much that 
is useful to the Physician and Pharmacist ; a general working formula 
for each class and an abstract formula for each officinal preparation, 
and many of the more popular unofficinal ones, together with their 
doses; also many symbolic formulas; a list of abbreviations used in 
prescription writing ; rules governing incompatibilities ; a list of 
Solvents ; tests for the more common drugs ; the habitat and best time 
for gathering plants to secure their medical properties. 

The book contains 180 pages, hy 2 x 8 inches, closely printed and 
on the best paper, nicely and durably bound, containing a greater 
amount of information on the above topics than any other work for the 
money. 

Price, in United States and Canada, post-paid, $1.50, net; 
Great Britain, 8s. 6d. ; France, 9 fr. 35. 



WITHERSTIIME— International Pocket Medical Formu- 
lary. Arranged Therapeutically. 

By C. Sumner Witherstine, M.S., M.D., Associate Editor of the 
"Annual of the Universal Medical Sciences ; " Visiting Physician of the 
Home for the Aged, Germantown, Philadelphia ; late House- Surgeon to 
Charity Hospital, New York. Including more than 1800 formulae from 
several hundred well-known authorities . With an Appendix containing 
a Posological Table, the newer remedies included; Important Incom- 
patibles; Tables on Dentition and the Pulse; Table of Drops in a 
Fluidrachm and Doses of Laudanum graduated for age ; Formulae and 
Doses of Hypodermatic Medication, including the newer remedies; Uses 
of the Hypodermatic Syringe; Formulae and Doses for Inhalations, Nasal 
Douches, Gargles, and Eye-washes; Formulae for Suppositories; Useof 
the Thermometer in Disease ; Poisons, Antidotes, and Treatment; Direc- 
tions for Post- Mortem and Medico-Legal Examinations; Treatment of 
Asphyxia, Sun-stroke, etc. ; Anti-emetic Remedies and Disinfectants; 
Obstetrical Table; Directions for Ligation of Arteries; Urinary Analy- 
sis; Table of Eruptive Fevers; Motor Points for Electrical Treatment, 
etc. This work, the best and most complete of its kind, contains about 
275 printed pages, besides extra blank leaves. Elegantly printed, with 
red lines, edges, and borders; with illustrations. Bound in leather, 
with Side-Flap. 

Price, in United States and Canada, post-paid, $83.00, net ; 
Great Britain, lis. 6d. ; France, 13 fr. 40. 

YOUNG— Synopsis of Human Anatomy. Being a Com- 
plete Compend of Anatomy, including the Anatomy 
of the Viscera, and Numerous Tables. 

By James K. Young, M.D., Instructor in Orthopaedic Surgery 
and Assistant Demonstrator of Surgery, University of Pennsylvania; 



Catalogue of Medical Publications. 



Attending Orthopaedic Surgeon, Out-Patient Department, University 
Hospital, etc. Illustrated with 76 Wood-Engravings. 390 pages. 12mo. 
No. 3 in the Physicians' and Students' Ready-Reference Series. 

Price, in United States and Canada, post-paid, 581.40, net ; 
Great Britain, 8s. 6d. ; France, 9 fr. 25. 

While the author has prepared this work especially for students, 
sufficient descriptive matter has been added to render it extremely 
valuable to the busy practitioner, particularly the sections on the 
Viscera, Special Senses, and Surgical Anatomy. 

The work includes a complete account of Osteology, Articulations 
and Ligaments, Muscles, Fascias, Vascular and Nervous Systems, 
Alimentary, Vocal, and Respiratory and Genito-Urinary Apparatus, 
the Organs of Special Sense, and Surgical Anatomy. 

In addition to a most carefully and accurately prepared text, 
wherever possible, the value of the work has been enhanced b}^ tables 
to facilitate and minimize the labor of students in acquiring a thorough 
knowledge of this important subject. The section on the teeth has 
also been especially prepared to meet the requirements of students 
of dentistry. 

In its preparation, Gray's "Anatomy" (last edition), edited by 
Keen, being the anatomical work most used, has been taken as the 
standard. 



The following Publications sold only by Subscription, 

or Sent Direct on Receipt of Price, Shipping 

Expenses Prepaid. 

Annual of the Universal Medical Sciences. A Yearly 

Report of the Process of the General Sanitary 
Sciences Throughout the World. 

Edited by Charles E. Sajous, M.D., formerly Lecturer on Laryn- 
gology and Rhinology in Jefferson Medical College, Philadelphia, etc., 
and Seventy Associate Editors, assisted by over Two hundred Corre- 
sponding Editors and Collaborators. In Five Royal Octavo Volumes of 
about 500 pages each, bound in Cloth and Half-Russia, Magnificently 
Illustrated with Chromo-Lithographs, Engravings, Maps, Charts, and 
Diagrams. Being intended to enable any physician to possess, at a 
moderate cost, a complete Contemporaiw History of Universal Medi- 
cine, edited by many of America's ablest teachers, and superior in 
every detail of print, paper, binding, etc., a befitting continuation of 
such great works as " Pepper's System of Medicine," " Ashhurst's In- 
ternational Encyclopaedia of Surgery," "Buck's Reference Hand- 
Book of the Medical Sciences." 



F. A. Davis, Philadelphia, Pa. 19 

SUBSCRIPTION PRICE Per Year (Including the "SATEL- 
LITE" for one year) : in United States, Cloth, 5 Vols., 
Royal Octavo, $ 15.00, Half-Russia, 5 Vols., Royal Oc- 
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Russia, $22.00. Great Britain, Cloth, <£4 7s ; Half-Rus- 
sia, £5 15s. France, Cloth, 93 fr. 95 ; Half-Russia, 124 
fr. 35. 

The Satellite of the "Annual of the Universal Medical 
Sciences." A Monthly Review of the most important articles upon 
the practical branches of Medicine appearing in the medical press at 
large, edited by the Chief Editor of the Annual and an able staff. 
Published in connection with the Annual, and for its Subscribers Only. 

Lectures on Nervous Diseases. From the Stand-point of 
Cerebral and Sp>inal Localization, and the Later 
Methods Employed in the Diagnosis and Treatment 
of these Affections. 

By Ambrose L. Rannet, A.M., M.D., Professor of the Anatomy 
and Physiology of the Nervous System in the New York Post-Graduate 
Medical School and Hospital ; Professor of Nervous and Mental 
Diseases in the Medical Department of the University of Vermont, etc. ; 
Author of " The Applied Anatomy of the Nervous System," " Prac- 
tical Medical Anatomy," etc. , etc. Profusely Illustrated with Original 
Diagrams and Sketches in Color by the author, carefully selected 
Wood-Engravings, and Reproduced Photographs of Typical Cases. 
One handsome Royal Octavo volume of 780 pages. 

Price, in United States, Cloth, $5.50; Sheep, $6.50 ; Half- 
Russia, $7.00. Canada (duty paid), Cloth, $6.05 ; Sheep, 
$7.15; Half-Russia, $7.70. Great Britain, Cloth, 32s,; 
Sheep, 37s. 6d.; Half-Russia, 4 0s. France, Cloth, 34 
fr. 70 ; Sheep, 40 fr. 45 ; Half-Russia, 43 fr. 30. 

Lectures on the Diseases of the Nose and Throat. De- 
livered at the Jefferson Medical College, Philadel- 
phia. 

By Charles E. Sajous, M.D., formerly Lecturer on Rhinology 
and Laryngology in Jefferson Medical College ; Vice-President of the 
American Laryngological Association ; Officer of the Academy of 
France and of Public instruction of Venezuela ; Corresponding Mem- 
ber of the Royal Society of Belgium, of the Medical Society of War- 
saw (Poland), and of the Society of Hygiene of France ; Member of 
the American Philosophical Society, etc., etc. Illustrated with 100 
Chromo-Lithographs, from Oil-Pain tings by the author, and 93 En- 
gravings on Wood. One handsome Royal Octavo volume. 

Price, in United States, Cloth, Royal Octavo, ©4.00 ; Half- 
Russia, Royal Octavo, $5. 00. Canada (duty paid), Cloth, 
84.40; Half-Russia, So. 50. Great Britain, Cloth, 22s. 6d ; 
Sheep or Half-Russia, 28s. France, Cloth, 24 fr. 60; 
Hali-Russia, 30 fr. 30. 



20 Catalogue of Medical Publications. 

Stanton's Practical and Scientific Physiognomy ; or How 
to Read Faces. 

By Mary Olmsted Stanton. Copiously Illustrated. Two large 
Octavo volumes. 

The author, Mrs. Mary O. Stanton, has given over twenty years 
to the preparation of this work. Her style is easy, and, by her happy 
method of illustration of every point, the book reads like a novel and 
memorizes itself. To physicians the diagnostic information conveyed 
is invaluable. To the general reader each page opens a new train of 
ideas. (This book has no reference whatever to Phrenology.) 

Price, in United States, Cloth, $9.00; SHeep, $11. 00; Half- 
Kussia, $13.00. Canada (duty paid), Cloth, $10.00; 
Sheep, $12.10; Hall-Russia, $14.30. Great Britain, 
Cloth, 56s. ; Sheep, 68s. ; Hall-Russia, 80s. France, 
Cloth, 30 ir. 30 ; Sheep, 36 fr. 40 ; Half-Russia, 43 ir. 30. 

Sold only by Subscription, or sent direct on receipt of price, ship- 
ping expenses prepaid. 

Journal of Laryngology and Rhinology. 

Issued on the First of Each Month. Edited by Dr. Norris 
Wolfenden, of London, and Dr. John Macintyre, of Glasgow, with 
the active aid and co-operation of Drs. Dundas Grant, Barclay J. 
Baron, Hunter Mackenzie, and Sir Morell Mackenzie. Besides 
those specialists in Europe and America who have so ably assisted in 
the collaboration of the Journal, a number of new correspondents 
have undertaken to assist the Editors in keeping the Journal up to 
date, and furnishing it with matters of interest. Amongst these are : 
Drs. Sajous, of Philadelphia ; Middlemass Hunt, of Liverpool ; 
Mellow, of Rio Janeiro; Sedziak, of Warsaw; Draispul, of St. 
Petersburg, etc. Drs. Michael, Joal, Holger Mygind, Prof. 
Massei, and Dr. Valerius Idelson will still collaborate the literature 
of their respective countries. 

Price, 13s. or $3.00 per annum (inclusive of Postage). 
For single copies, however, a charge of Is. 3d. (30 
Cents) will be made. Sample Copy, 25 Cents. 

The Medical Bulletin. 

Edited by John V. Shoemaker^ A.M., M.D. Monthly; $1.00 a 
year. Bright, Original, and Readable. Articles by the best practical 
writers procurable. Every article as brief as is consistent with the 
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